Introduction of quality indicators in German hospital capacity planning - Do results show an improvement in quality?

In Germany, the use of quality data to support hospital capacity planning was introduced in 2017. On behalf of the Federal Joint Committee, IQTIG suggested 11 quality indicators and developed a program on how to collect, evaluate and report data for the clinical areas gynaecological surgery, obstetrics and breast surgery. By analysing data from 2015 to 2021, effects of the introduction of the program on indicator results, statistical discrepancies and impact on care quality are examined. Effects on capacity planning are discussed. Since the program started, indicator results improved in all clinical areas, and statistical discrepancies and the number of assessments with insufficient quality decreased due to enhanced adherence to quality standards and data validity. Effects on capacity planning or the allocation of hospitals have not occurred. Thus, a change of the legal basis to allow a better link between quality and hospital planning is recommended. The approach to use quality data on hospital regulation in Germany is evolving. The current hospital reform in Germany also addresses other approaches to quality-based regulation. Already now, there have been clear improvements in specific indicators as well as lessons for quality assurance and its link to capacity planning provided by the program, which are also applicable to other countries.

Development of quality indicators and data assessment strategies for the prevention of central venous catheter-related bloodstream infections (CRBSI).

BACKGROUND: The number of catheter related bloodstream infections (CRBSI) could be reduced and the outcome improved if specific standards in the quality of care were maintained. Therefore, the development of quality assurance (QA) procedures was commissioned to be included in the national mandatory QA programme in Germany. METHODS: Indicators representing quality deficiencies and potential for improvement of quality in relation to prevention and management of central venous catheters (CVC) were developed by (1) evidence-based literature searches and the compiling of an indicator register; (2) a multi-professional expert panel including patient representatives who selected indicators from this register by using a modified RAND/UCLA Appropriateness Method; (3) defining methods for data assessment, risk adjustment and feedback of indicator results to service providers; and (4) consulting all relevant medical societies and other stakeholders with regard to the QA procedures that had been developed. RESULTS: Thirty-two indicators for CRBSI prevention and management were eventually approved by the expert panel. These indicators represent quality of care at predefined points with regard to indication, insertion and care of CVCs, management of sepsis, general hygiene and training of health care personnel. Fourteen indicators represent processes, together with 7 representing structures and 11 outcomes. For assessing these indicators, data was obtained from four sources: claims data from health insurance funds, routine claims data from hospital electronic information systems, case specific longitudinal documentation from service providers and cross-sectional annual assessment of structures. CONCLUSIONS: It was possible to develop indicators for mandatory QA procedures on CRBSI that take into account the different perspectives of all stakeholders involved. Despite efforts to use routine data for documentation wherever possible, most indicators required extra documentation.

Developing cross-sectoral quality assurance for cataract surgery in the statutory quality assurance program of the German health care system: Experiences and lessons learned.

Since 2001, statutory external quality assurance (QA) for hospital care has been in place in the German health system. In 2009, the decision was taken to expand it to cross-sectoral procedures. This novel and unprecedented form of national QA aims at (1) making the quality procedures comparable that are provided both in inpatient and outpatient care, (2) following-up outcomes of hospital care after patients' discharge and (3) measuring the quality of complex treatment chains across interfaces. As a pioneer procedure a QA procedure in cataract surgery QA was developed. Using this as an example, challenges of cross-sectoral QA are highlighted. These challenges relate, in particular, to three technical problems: triggering cases for documentation, following-up patients' after hospital discharge, and the burden of documentation in outpatient care. These problems resulted finally in the haltering of the development of the QA procedure. However, the experiences gained with this first development of cross-sectoral QA inspired the reorientation and further development of the field in Germany. Future cross-sectoral QA will rigorously aim at keeping burden of documentation small. It will draw data for QA mainly at three sources: routine data, patient surveys and peer reviews using indicators. Policy implications of this reorientation are discussed.

Coronary procedures in German hospitals: a detailed analysis for specific patient clusters.

OBJECTIVES: Evaluation of the classification of the patients with coronary procedures [CP: coronary angiography (CA) and/or percutaneous coronary intervention (PCI)] in Germany to provide valid data as a basis for the evaluation of resource planning and comparison of results from other countries. BACKGROUND: In the case of CP, most data are restricted to procedures related to acute coronary syndrome (ACS), either STEMI or NSTEMI, and does not cover the whole range of coronary angiographies and therapeutic procedures. To contribute to the clarification of this situation, our analysis was performed. METHODS: The data of all patients with CP documented according to § 137 German Social Security Code V (SGB V) by hospitals registered under the requirements of § 108 SGB V were analyzed. By cluster analysis, the most important predictors for four short-term clinical outcomes (intra-procedural and post-procedural events, death, length of hospital stay) were identified. Differences were analyzed on a national, federal state and interstate level. RESULTS: In 2012, 764,233 CP were performed in 733,337 patients (64.7 % males) in 890 hospitals. In 88.2 % of all patients, a cardiac disease was detected; in 11.3 %, it was excluded. 5 clusters were identified which were based on the following parameters: ACS, invasive coronary procedure, cardiac disease (i.e., hypertensive cardiac disease, cardiomyopathy, aortic aneurysm, cardiac valve disease), exclusion of CHD. There were significant differences between the five patient clusters: percentages of patients with diabetes, renal insufficiency and CHF varied between 14.1 and 32.9 %, 9.5 and 31.6 %, and 7.0 and 16.9 %, respectively; average duration of hospitalization and death rates varied between 5.5 (without ACS) and 8 days (ACS) and 0.3 and 4.5 %, respectively. The distribution of patient clusters varied significantly between the German federal states as well as within a federal state. CONCLUSIONS: Five patient clusters with CP showed significantly differing profiles of risk, outcome and resource consumption as well as a regional distribution. This has to be considered for comparisons between hospitals as well as on a regional and international level and hospital planning.

Patient controlled analgesia for extracorporeal shock wave lithotripsy of gallstones.

Sixty patients undergoing shock wave lithotripsy of gallbladder stones (ESWL) were randomly assigned to receive alfentanil either by infusion controlled by the attending anesthesiologist (standard treatment group, n = 31) or by analgesia controlled by the patient (PCA group, n = 29). Patients using PCA were allowed to self-administer 0.25 mg of alfentanil i.v. every minute as required. Data collected during treatment included the total dose of drug required, transcutaneous pCO2 values, verbal pain and sedation scores, visual analogue scale (VAS) patient satisfaction scores, and the incidence of nausea or vomiting. PCA patients used less alfentanil than the standard treatment group (PCA group: 12.8 micrograms/kg; standard treatment group: 44.3 micrograms/kg; mean values, P = 0.0001), tolerated significantly higher pain intensities and self-administered the narcotic only to moderate levels of pain but not to pronounced analgesia. Standard treatment patients reported lower levels of pain, were more sedated (P less than 0.05) and showed significantly higher transcutaneous pCO2 values. There was a trend towards a lower incidence of nausea or vomiting in PCA patients without reaching statistical significance. No significant difference with regard to patient satisfaction with pain relief could be demonstrated. Self-administered alfentanil during ESWL of gallbladder stones provided adequate analgesia with minimal side effects and high patient satisfaction. ESWL may represent a new and useful indication for PCA.