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The incidence of esophageal carcinoma has increased in recent years in Germany. The aim of this article is a discussion of the economic aspects of oncological esophageal surgery within the German diagnosis-related groups (DRG) system focusing on the association between minimum caseload requirements and outcome quality as well as costs. The margins for the DRG classification G03A are low and quickly exhausted if complications determine the postoperative course. A current study using nationwide German hospital discharge data proved a significant difference in hospital mortality between clinics with and without achieving the minimum caseload requirements for esophagectomy. Data from the USA clearly showed that besides patient-relevant parameters, the caseload of a surgeon is relevant for the cost of treatment. Such cost-related analyses do not exist in Germany at present. Scientific validation of reliable minimum caseload numbers for oncological esophagectomy is desirable in the future.

Objectives: To evaluate the appropriateness of emergency referrals for inter-hospital transfers by local physicians in hospitals without intensive care facilities to a regional tertiary paediatric intensive care unit (PICU)., Design: A prospective, descriptive study in a tertiary PICU and hospitals without paediatric intensive care facilities in and around the London area, UK., Patients: All patients (< 18 years) referred for emergency admission to the PICU from district hospitals (n = 436) as well as those admitted through other modes of admission (n = 286) between 1 October 1998 and 30 June 1999 were prospectively studied. Admissions and transfers were deemed appropriate if the risk of mortality using the Paediatric Risk of Mortality (PRISM II) score was greater than 1%, and/or if the patient required a unique ICU-dependent therapy. Effectiveness was estimated using PRISM II derived observed-to-expected mortality ratio. Of the 436 emergency referrals 398 (91.3%) were retrieved and transported to the PICU. Of these, 38 referrals were thought to be inappropriate after telephone consultation and were not transferred. Of the emergency referrals 376 (94.4%) had a mortality risk greater than 1% or required an ICU-dependent therapy on admission day. Thus 86.2% (376/436) of the referrals and 94.4% (376/398) of transfers were considered appropriate. The PRISM II derived standardized mortality rate was 0.694 (95% CI 0.517-0.913) in the overall population and 0.613 (95% CI 0.434-0.843) amongst the emergency referrals., Conclusion: Physicians at local hospitals within a centralized system of delivering paediatric intensive care were able to maintain adequate assessment skills in recognition and requesting for appropriate transfers of the most ill and efficiently utilized resources available at the regional centre.

The study provides empirical data to compare different systems used for hospital admission procedures in a psychiatric clinic. The Psychiatric University Clinic Basel replaced its traditional central admission ward by direct admission to a number of different treatment settings. This change had consequences for both structural and procedural quality. More admissions occurred after prior notice had been given, and these admissions occurred more often at a time of day when more clinic staff were available. The rate of voluntary admissions increased, and the continuity of care, as measured by the number of transfers within the clinic during the first 5 days post-admission, was improved. These findings, which support an interpretation that the treatment conditions were improved, must be balanced against the drawback of delayed decision-making processes with, for example, longer waiting times for the patient. However, the continuity of therapeutic relationships can be increased through further changes in the procedural quality.