翻修关节成形术中的巨大内假体——aG DRG系统中的成本收益分析。

Zeitschrift fur Orthopadie und Unfallchirurgie Pub Date : 2024-12-01 Epub Date: 2023-10-23 DOI:10.1055/a-2174-1439
Katharina Awwad, Carsten Gebert, Marcel Dudda, Jendrik Hardes, Arne Streitbürger, Yannik Hanusrichter, Martin Wessling
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引用次数: 0

摘要

大型内假体在复杂的翻修关节成形术病例中提供了一种可行的治疗方法,具有良好的功能效果。在肿瘤适应症的背景下,诊断相关组(DRG)I95A的相对权重通常为4.906(2021)。相反,在翻修关节成形术中,根据关节置换术的不同,指定了合适的DRG。与发票DRG相比的额外费用将通过商定医院特定的个人费用进行补偿。这些复杂的翻修关节置换术对技术和手术要求很高,主要在专业科室进行。作为一项单中心研究,我们对专业骨科诊所翻修病例中使用巨型内假体进行了成本效益分析。我们试图回答的问题是:在修改后的德国DRG系统(aG-DRG)中,成本回收可能吗?对治疗费用进行了回顾性单中心分析。从2018年到2020年,113名患者因髋关节或膝关节假体无菌或感染性翻修后大面积骨丢失,在转诊中心接受了大型内假体重建治疗,纳入了该研究。aG DRG矩阵的相关病例相关成本驱动因素(包括手术室区域和病房的人员和材料成本)被考虑在内。实际费用是根据德国医院薪酬制度研究所出版的计算手册的规范确定的。对于每种情况,通过将医院的内部成本与aG DRG矩阵的相应成本池相关联来计算贡献率。根据2021年DRG系统,17种不同的DRG用于计费,其中70%基于患者临床复杂性水平(PCCL)≥4。与InEK计算相比,所检查的参数中每个病例的赤字为-2901欧元。医生的费用显示手术室和病房都存在短缺。植入成本本应通过医院特有的额外费用来补偿,但医院特有的短缺为-2181欧元。在分析成本回收的风险因素时,只有这些因素显示出显著差异。在翻修关节成形术中植入巨大内假体通常是保留肢体功能的最后选择。目前,尽管有高度的专业化和流程优化,但即使在三级护理中,这种治疗也无法实现成本效益。政治上需要的专门部门结构需要对复杂案件进行充分补偿。每个治疗病例的经济结果往往是不可预测的,然而外科医生面对这些病例,并期望对其进行治疗。高标准偏差表明每个案例的成本/收入情况存在很大差异。我们的研究结果首次显示了翻修关节成形术中大型假体的实际成本分析,并强调了由资助单位单独商定的充足的医院专用费用的重要性。计算不仅应包括植入成本,还应包括增加的员工成本(增加的、复杂的规划工作、质量管理、手术时间等)。
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The Megaendoprosthesis in Revision Arthroplasty - a Cost-revenue Analysis in the aG-DRG System.

Megaendoprosthesis offer a viable treatment in complex revision arthroplasty cases with good functional outcome. In the context of a neoplastic indication, the diagnosis-related group (DRG) I95A is usually assigned with a relative weight of 4.906 (2021). In contrast, in revision arthroplasty, the appropriate DRG is assigned, depending on the joint replacement. The additional costs compared to the invoiced DRG are to be compensated by agreeing on hospital-specific individual fees. These complex revision arthroplasties set high technical and operative demands and are mainly performed in specialised departments. We conducted a cost-benefit analysis of the use of the megaendoprosthesis in revision cases in a specialised orthopaedic clinic, as a single centre study. The question we sought to answer was: Is cost recovery possible in the modified German DRG system (aG-DRG)?A retrospective single centre analysis of treatment costs was performed. From 2018 to 2020, 113 patients treated with a megaendoprosthesis reconstruction in a referral centre due to extensive bone loss after aseptic or septic revision of a hip or knee prosthesis were included in the study. Relevant case-related cost drivers of the aG-DRG matrix (including staff and material costs of the operating theatre area and the ward) were taken into account. The actual costs were determined according to the specifications of the calculation manual published by the German institute for the remuneration system in hospitals (InEK). For each case, the contribution margin was calculated by relating the hospital's internal costs to the corresponding cost pool of the aG-DRG matrix.According to the DRG system 2021, 17 different DRGs were used for billing - in 70% based on a patient clinical complexity level (PCCL) ≥ 4. Compared with the InEK calculation, there is a deficit of -2,901 € per case in the examined parameters. The costs of physicians show a shortfall in both the operating theatre and on the ward. Implant costs, which were supposed to be compensated by hospital-specific additional charges, show a hospital-specific shortage of -2,181 €. When analysing the risk factors for cost recovery, only these showed a significant difference.Implantation of the megaendoprosthesis in revision arthroplasty is often the last option to preserve limb function. At present, despite a high degree of specialisation and process optimisation, this treatment cannot be provided cost-effectively even in tertiary care. The politically desired specialised department structure requires sufficient reimbursement for complex cases. The economic outcome of each treatment case is often unpredictable, however the surgeon is confronted with these cases and is expected to treat them. The high standard deviation indicates large differences in the cost/revenue situation of each individual case. Our results show for the first time a realistic cost analysis for megaprosthesis in revision arthroplasty and underline the importance of an adequate hospital-specific charge, individually agreed by the funding units. The calculation should include not only the implant costs, but also the increased staff costs (increased, complex planning effort, quality management, surgery time, etc.).

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