gms | German Medical Science

Background: The necessity of reliable quality measurement and control as the basic tools to ensure delivery of the best possible care and improvement in surgery is most widely accepted. It has been shown though that the documentary effort of the medical staff, being in many hospitals surgical residents, can be the limiting factor for the reliability of the respective measurement. A popular allegation of critics of the current DRG-system is that this system reimburses complications better than an uneventful course of treatment.

Materials and methods: Rates of surgical site infections (SSI) were recorded with the departmental standard morbidity measurement from more than 20.000 patients in a weekly recording from 2006 until 2014. Due to yielding relatively low morbidity rates, the quality measurement system was changed, which lead to a notable increase in recorded morbidity. These rates of SSI were compared with the InEK data of the surgical maximum care center for the years 2009-2014 comprising more than 15.000 cases employing the ICD complication code T81.4 for postoperative infection. The cases allocated to the ICD T81.4 were compared with each years mean cost coverage for all patients.

Results: With the early morbidity assessment system from 2006 until 2014, a low yearly rate of 2.5% SSI was noted, the rate increased by 60% after the introduction of the new quality measurement concept, ranging around 4% in 2014/2015 with a generally higher rate of recorded morbidity. The InEK data yielded an average of 5.2% cases with T81.4 from 2009-2014 (range 3.7-6.1%). Concerning the economic aspect, the DRG cost coverage for the years 2009-2014 resulted in a mean negative result of -3.1% for all cases. For cases with the T81.4 code the mean cost deficit amounted to -7.4%, therefore doubling the negative effect (p<0.001).

Conclusion: The routine data provided consistent evidence for SSI at a slightly higher rate than the in-house quality measurement and contained the economic information of this group of cases. The downside of the ICD-coding is the lack of medical specificity, as it cannot serve as a substitute for a morbidity classification, e.g. the Clavien-Dindo classification. Different degrees of SSI still need to be classified and acted upon. All efforts need to be undertaken to accurately assess the true rates of complications and their deleterious effects to take appropriate measures for their reduction. This analysis clearly contradicts the allegation that the DRG-system reimburses cases with complications better than an uneventful course. The resulting mission statement: Improve your quality and get your costs down.