Routine saves lives

Martin Litsch chose drastic words: “In Germany people live every day unnecessarily put at risk”, said the Chairman of the Board of the AOK-Federal Association, as last December in Berlin, the “quality monitor 2019” was presented. The report provides case and quality indicators for selected disease pictures and treatments in German hospitals.

Litsch moved to its statement on the most vulnerable patients, premature infants. Currently, a clinic in Germany early in Chen provide, if you have at least 14 cases per year. In Litschs eyes are much too little: “Every year, without the proper minimum amount in this sensitive and complex area of fatal consequences for the affected children and their parents.”

Also the Association of “The early-born child” asks for already since 2010, the minimum quantity for the early supply of 14 to 30 raise. At the time, he noted that, “obviously, therefore, many early-born children have to die because too many clinics to treat a few early-born, and lacking therefore the necessary experience in dealing with the very smallest.”

The Federal social court has not cashed the increase in the minimum amount of time, however, on the grounds that the connection between quantity and quality used in this case to narrow academic criteria, but only “probably”.

The more, the better?

In addition to the premature baby care of the Federal Joint Committee (G-BA) amounts for the six other medical interventions minimum: for kidney and liver transplants, complex interventions on the esophagus and pancreas, stem cell transplants and implantation of knee joint endoprostheses (knee TEP).

The idea behind the case number definition: If in the case of a planned SURGERY, the risk of serious complications high, it needs to be lowered, that only in hospitals, which will be operated on, perform the corresponding procedure often. “Volume-Outcome effect,” call the experts.

The approach is reasonable, the implementation was sloppy. A significant proportion of the clinics ignored the requirements, sanctions there were none. In part, it came to clashes, which landed in front of social courts.

No minimum quantity, no money

That should change now. On the basis of the hospital act, all hospitals in these areas must 15, to. July 2019 to predict how many interventions you plan to 2020. Houses that don’t assume that you reach the minimum amount, not more get the performance of the funds and then be reimbursed. Transitional arrangements and derogations provided for offences.

The quality monitor provides information about how many clinics could be affected – exact Numbers do not exist: So in 2016, were glands a fifth of all 11.290 pancreatic surgery hospitals performed below the minimum amount of ten interventions per year. The 4139 esophageal surgery failed even to around 40 per cent of the 295 hospitals, the minimum quantity is 10. In the case of the knee joints, Figures from 2011 show that around 15 percent of the 141.928 implantations were carried out at a clinic (total 1024) below minimum quantity.

Protest against the minimum quantities of stimulates, especially in transplantation medicine, the power due to their small amount of interventions and centres other parameters for apply.

The German society for Orthopaedics and trauma surgery (DGOU) would, however, like to even stricter rules: Effective personal minimum amount, according to a Statement by the DGOU, for a fixed number of cases per surgeon. The future control of individual hospitals from the supply termination, which were allowed to operate due to exceptional rules would be, although the minimum quantity of steps. This will not, however, change the care of patients serious.

This evaluation Thomas Mansky, the deals for years, scientifically, how the quantity affects the quality. The just-retired, former head of the Department of structural development and quality management in health care at the faculty of Economics of the TU Berlin complains that it is not specialized to a lot of small hospitals – and this is a structural problem. “We make the medicine of the 21st century. Century in the structures of the middle of the 20th century. Century, partly in the 19th century. Century are grown,” says Mansky.

“Mass diseases are not taken into account”

That this will change in the near future, Mansky believes. Therefore, he is committed – as in the quality monitor recorded, he has worked to extend the minimum quantities. “The real mass disorders have not been taken into account yet,” said the doctor.

Scientific evidence for the correlation between high volume and better treatment results there are many to be found here, here, and here. In a nationwide observational study from 2009 to 2014, about could the research group, Mansky also beyond the currently existing minimum levels for 20 of the 25 surveyed clinical pictures a relationship between the number of treated patients and the hospital mortality is demonstrated.

Particularly significantly, the data for complex interventions on the esophagus and pancreas, but also in the treatment of heart attacks, the results were clear. The G-BA advises according to own statements, currently, also in the surgical treatment of breast and lung cancer minimum quantities.