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Impact of suspending minimum volume requirements for knee arthroplasty on hospitals in Germany: an uncontrolled
Werner de Cruppé1, Annette Ortwein2, Rike Antje Kraska3
1Institute for Health Services Research and Clinical Epidemiology, Philipps-Universität Marburg, Karl-von-Frisch-Strasse 4, 35043, Marburg, Germany. decruppe@uni-marburg.de.
Background:
In 2004, the Federal Joint Committee, supreme decision-making body in German healthcare, introduced minimum volume requirements (MVRQs) as a quality instrument. Since then, MVRQs were implemented for seven hospital procedures. This study evaluates the effect of a system-wide intermission of MVRQ for total knee arthroplasty (TKA), demanding 50 annual cases per hospital.
Methods:
An uncontrolled before-after study based on federal-level data including the number of hospitals performing TKA, and TKA cases from the external hospital quality assurance programme in Germany (2004-2017). Bi- and multivariate analyses based on hospital-level secondary data of TKA cases and TKA quality indicators extracted from hospital quality reports in Germany (2006-2014).
Results:
The number of TKAs performed in Germany decreased by 11% after suspending the TKA-MVRQ in 2011, and rose by 13% after its reintroduction in 2015. The number of hospitals with less than 50 cases rose from 10 to 25% and their case share from 2 to 5.5% during suspension. Change in hospital volume after the suspension of TKA-MVRQ was not associated with hospital size, ownership, or region. All four evaluable quality indicators increased significantly in the year after their first public reporting. Compared to hospitals meeting the TKA-MVRQ, three indicators show slight but statistically significant better quality in hospitals below the TKA-MVRQ.
Conclusions:
In Germany, TKA-MVRQs seem to induce in-hospital caseload adjustments rather than foster regional inter-hospital case transfers as intended.
Insights
Suspending minimum volume requirements for total knee arthroplasty (TKA) in Germany led to fewer TKAs and more low-volume hospitals. Reintroduction increased TKA numbers, suggesting MVRQs influence caseloads within hospitals.
Area of Science:
- Healthcare Quality Management
- Surgical Procedure Analysis
- Health Services Research
Background:
- Minimum volume requirements (MVRQs) were implemented in German healthcare in 2004 to improve quality.
- MVRQs have been applied to seven hospital procedures, including total knee arthroplasty (TKA).
- This study examines the impact of a temporary suspension of TKA MVRQs (50 cases/hospital/year).
Purpose of the Study:
- To evaluate the effects of suspending and reintroducing MVRQs for TKA in Germany.
- To assess how MVRQs influence hospital caseloads and case distribution for TKA.
- To analyze the relationship between TKA MVRQs and quality indicators.
Main Methods:
- An uncontrolled before-and-after study design was used.
- Federal-level data on TKA procedures and hospital numbers (2004-2017) were analyzed.
- Hospital-level data on TKA cases and quality indicators (2006-2014) underwent bi- and multivariate analysis.
Main Results:
- TKA procedures decreased by 11% after MVRQ suspension and increased by 13% after reintroduction.
- Hospitals with <50 cases rose from 10% to 25%, with their case share increasing from 2% to 5.5% during suspension.
- While quality indicators generally improved, hospitals below the MVRQ threshold showed slightly better quality in three indicators compared to those meeting it.
Conclusions:
- TKA MVRQs in Germany appear to influence caseload adjustments within hospitals.
- The system did not effectively promote inter-hospital case transfers as intended.
- The findings suggest MVRQs may impact hospital operational strategies more than regional resource allocation.
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