DÄ internationalArchive7/2013Room for Improvement
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The publication (1) shows that the mortality risk for preterm infants with a birth weight below 1250 g is considerably and significantly lower in centers treating 30 or more cases every year than in centers with fewer than 30 cases/year. If all preterm infants had been treated in such hospitals then mortality for the entire group would likely have been lower. This primary result must not be overshadowed by more detailed results.

The heterogeneity of hospitals with 30 or more cases is, however, considerable. If the quality results were known for individual hospitals, it might be assumed that—if timely data were available and quality results were consistent over time—then, as a second step, overall mortality would drop to even lower levels.

If the quality results regarding mortality and morbidity could be modeled with greater accuracy (for example by improved risk adjustment, as suggested by Vogtmann et al. [2]), then a further improvement in the results (third step) could be expected, if cases were concentrated in higher-quality hospitals.

The primary result, that centers with more than 30 cases/year on average achieve better results, has the advantage of being generally useful in terms of the management and steering of service provision. In contrast the improvement potentials, if more accurate quality results were obtained and known for individual hospitals, could be more difficult to realize, as e.g. the results of individual centers are subject to uncertain changes over time. Other generalizable characteristics should also be determined (for example, characteristics of the structural quality, such as provision of certain intervention options, qualified staff, etc). It can be difficult to show that such characteristics are reliably associated with adequately risk-adjusted quality results, and infer causality on this basis. In a scenario where such characteristics are lacking, Kutschmann et al. (1) at least showed that the number of cases is a relevant criterion.

The Federal Joint Committee (Gemeinsamer Bundes­aus­schuss, G-BA) was well advised to set a minimum caseload, which ensures centralization and better quality care – and therefore the likelihood of survival of preterm infants.

DOI: 10.3238/arztebl.2013.0116a

Dipl.-Med. Hans-Werner Pfeifer, Leiter Referat Qualitätssicherung
GKV-Spitzenverband, Berlin, Hans-Werner.Pfeifer@gkv-spitzenverband.de

Conflict of interest statement

The author declares that no conflict of interest exists according.

1.
Kutschmann M, Bungard S, Kötting J, Trümner A, Fusch C, Veit C:
The care of preterm infants with birth weight below 1 250 g: risk-adjusted quality benchmarking as part of validating a caseload-based management system. Dtsch Arztebl Int 2012; 109(31–32): 519–26 VOLLTEXT
2.
Vogtmann C, Koch R, Gmyrek D, Kaiser A, Friedrich A: Risk-adjusted intraventricular hemorrhage rates in very premature infants – towards quality assurance between neonatal units. Dtsch Arztebl Int 2012; 109(31–32): 527–33. VOLLTEXT
1.Kutschmann M, Bungard S, Kötting J, Trümner A, Fusch C, Veit C:
The care of preterm infants with birth weight below 1 250 g: risk-adjusted quality benchmarking as part of validating a caseload-based management system. Dtsch Arztebl Int 2012; 109(31–32): 519–26 VOLLTEXT
2. Vogtmann C, Koch R, Gmyrek D, Kaiser A, Friedrich A: Risk-adjusted intraventricular hemorrhage rates in very premature infants – towards quality assurance between neonatal units. Dtsch Arztebl Int 2012; 109(31–32): 527–33. VOLLTEXT

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