Impact of suspending minimum volume requirements for knee arthroplasty on hospitals in Germany: an uncontrolled before-after study.

BACKGROUND: In 2004, the Federal Joint Committee, supreme decision-making body in German healthcare, introduced minimum volume requirements (MVRQs) as a quality instrument. Since then, MVRQs were implemented for seven hospital procedures. This study evaluates the effect of a system-wide intermission of MVRQ for total knee arthroplasty (TKA), demanding 50 annual cases per hospital. METHODS: An uncontrolled before-after study based on federal-level data including the number of hospitals performing TKA, and TKA cases from the external hospital quality assurance programme in Germany (2004-2017). Bi- and multivariate analyses based on hospital-level secondary data of TKA cases and TKA quality indicators extracted from hospital quality reports in Germany (2006-2014). RESULTS: The number of TKAs performed in Germany decreased by 11% after suspending the TKA-MVRQ in 2011, and rose by 13% after its reintroduction in 2015. The number of hospitals with less than 50 cases rose from 10 to 25% and their case share from 2 to 5.5% during suspension. Change in hospital volume after the suspension of TKA-MVRQ was not associated with hospital size, ownership, or region. All four evaluable quality indicators increased significantly in the year after their first public reporting. Compared to hospitals meeting the TKA-MVRQ, three indicators show slight but statistically significant better quality in hospitals below the TKA-MVRQ. CONCLUSIONS: In Germany, TKA-MVRQs seem to induce in-hospital caseload adjustments rather than foster regional inter-hospital case transfers as intended.

Patient safety in ambulatory care from the patient's perspective: a retrospective, representative telephone survey.

OBJECTIVES: Data on patient safety problems (PSPs) in ambulatory care are scarce. The aim of the study was to record the frequency, type, severity and point of origin of PSPs in ambulatory care in Germany. DESIGN: Retrospective cross-sectional study. SETTING: Computer-assisted telephone interviews with randomly recruited citizens aged ≥40 years in Germany who were asked about their experiences with PSPs in ambulatory care. PARTICIPANTS: 10 037 citizens ≥40 years. MEASURES: A new questionnaire was developed to record patient experiences with PSPs in ambulatory care. The study reported here targets patient experiences in the last 12 months. The questionnaire focuses on PSPs in seven areas of medical treatment: anamnesis/diagnostic procedures; medication; vaccination, injection, infusion; aftercare; outpatient surgery; office administration; other areas. For each PSP reported, detailed questions were asked about the specialist group concerned, and, on the most serious harm, the severity of the harm and its consequences. The target parameters are presented as proportions with 95% CIs. RESULTS: 1422 of the respondents (14%) reported 2589 PSPs. The areas most frequently affected by PSPs were anamnesis/diagnostic procedures (61%) and medication (15%). General practitioners accounted for 44% of PSPs, orthopaedists for 15% and internists for 10%. 75% of PSPs were associated with harm, especially unnecessarily prolonged pain or deterioration of health; 35% of PSPs led to permanent harm. 804 PSPs (32%) prompted patients to see another doctor for additional treatment; 255 PSPs (10%) required inpatient treatment. CONCLUSION: PSPs experienced by patients are widespread in ambulatory care in Germany. The study reveals in which areas of medical treatment efforts to prevent PSPs could make the greatest contribution to improving patient safety. It also demonstrates the valuable contribution of patient reports to the analysis of PSPs.

Public reporting of hospital quality data: What do referring physicians want to know?

OBJECTIVE: To identify ambulatory care physicians' priorities for hospital quality criteria to support them in counselling patients what hospital to choose. METHODS: Three hundred non-hospital-based stratified randomly sampled physicians, representing the five main referring specialties in Germany participated in a cross-sectional survey. Physicians rated the importance of 80 hospital quality criteria to be used in their counselling of patients in need of hospital care. Criteria selection was based on a literature analysis and the content of Germany's mandatory hospital quality reports. We calculated the most important criteria and performed an ordinal regression analysis to examine whether the physicians' characteristics 'age', 'sex', 'specialty', 'practice type' and 'region' affected physicians' importance ratings. RESULTS: To counsel patients in need of a hospital referral, physicians preferred hospital quality criteria that reflect their own and their patients' experiences with a hospital. Additionally, hospitals' expertise and results of treatment were rated highly important. In contrast, hospitals' structural characteristics and compliance with external requirements were rated less important. Physicians' characteristics affected importance ratings only negligibly. CONCLUSIONS: To support referring physicians' counselling of patients regarding what hospital to choose in order to achieve optimal patient outcomes eventually, hospital report cards must be enriched by information on physicians' and their patients' experiences with hospitals. Hospitals' structural characteristics play a minor role in counselling of patients needing hospital care.