Reservations Regarding the Suitability of the DRG System

Deaths Following Cholecystectomy and Herniotomy by Ulrike Nimptsch, Prof. Dr. med. Thomas Mansky in issue 31–32/2015

In our opinion, the hospital discharge data (diagnosis related group [DRG] statistics) that provide the basis for the analysis (1) are not sufficiently suitable for assessing the actual morbidity and mortality after herniotomies. Most hernias are found in the catalogue of outpatient procedures according to §115b SGB [German Social Code Book] V. Outpatient hernia repairs account for about 20% of all hernia repairs in Germany (2). Similarly, the different surgical techniques with their completely different risk profiles were not taken into account. Primary hernias can differ enormously and are therefore difficult to represent in the DRG system (3). In some instances, more than 60 different surgical procedures are subsumed under one DRG, but in Europe, there are only three or four different ways of coding herniotomies in DRGs on average. This does not seem sufficient for generating relevant data (4).

The authors’ conclusion that the preoperative identification of risk could be optimized is consequently only partly valid. In the DRG-based analysis, it is impossible to differentiate between elective procedures and emergency operations. A highly acute incarcerated hernia, which according to the literature presents itself in about 5% of all cases (2), requires immediate action and is associated with substantially higher fatality rate than an elective procedure, which allows for individual preoperative optimization, as suggested. However, in rare cases, so-called watchful waiting is associated with a higher risk for hernia patients, but results in a different DRG classification in inpatients, which is not taken into account in the presented data.

It is our view that the DRG system as a hospital reimbursement system that was introduced in the context of an economy drive in Germany’s healthcare system (3) still does not allow valid conclusions about clinical procedures, despite many attempts to optimize it. In our opinion, hernia registries are a more appropriate instrument.

DOI: 10.3238/arztebl.2016.0250a

Dr. sc. hum. Dr. med. Kai Witzel

Minimal Invasiv Center Hünfeld, PMU Nürnberg

Dr. med. Ralph Lorenz

Praxis 3Chirurgen, Berlin

Conflict of interest statement

The authors declare that no conflict of interest exists.

References

1. Nimptsch U, Mansky T: Deaths following cholecystectomy and herniotomy—an analysis of nationwide German hospital discharge data from 2009 to 2013. Dtsch Arztebl Int 2015; 112: 535–43

2. Lorenz R, Koch A, Köckerling F: Ambulante und stationäre Hernienchirurgie in Deutschland – aktueller Stand. CHAZ 2015; 5: 267–76

3. Rudroff C, Schweins M, Heiss MM: The quality of patient care under the German DRG system using as example the inguinal hernia repair. Zentralbl Chir 2008; 133: 51–4

4. Serdén L, O’Reilly J: Patient classification and hospital reimbursement for inguinal hernia repair: a comparison across 11 European countries. Hernia. 2014;18: 273–81