Search

Introduction In emergency care, geriatric requirements and risks are often not taken sufficiently into account. In addition, there are neither evidence-based recommendations nor scientifically developed quality indicators (QI) for geriatric emergency care in German emergency departments. As part of the GeriQ-ED© research project, quality indicators for geriatric emergency medicine in Germany have been developed using the QUALIFY-instruments. Methods Using a triangulation methodology, a) clinical experience-based quality aspects were identified and verified, b) research-based quality statements were formulated and assessed for relevance, and c) preliminary quality indicators were operationalized and evaluated in order to recommend a feasible set of final quality indicators. Results Initially, 41 quality statements were identified and assessed as relevant. Sixty-seven QI (33 process, 29 structure and 5 outcome indicators) were extrapolated and operationalised. In order to facilitate implementation into daily practice, the following five quality statements were defined as the GeriQ-ED© TOP 5: screening for delirium, taking a full medications history including an assessment of the indications, education of geriatric knowledge and skills to emergency staff, screening for patients with geriatric needs, and identification of patients with risk of falls/ recurrent falls. Discussion QIs are regarded as gold standard to measure, benchmark and improve emergency care. GeriQ-ED© QI focused on clinical experience- and research-based recommendations and describe for the first time a standard for geriatric emergency care in Germany. GeriQ-ED© TOP 5 should be implemented as a minimum standard in geriatric emergency care.

Quality indicators are used world-wide to control the quality of health care. To be effective these indicators have to meet quality criteria themselves. But until now there has been no fully operational method for assessing indicators. Using a systematic review of existing criteria and scientific analyses the criteria set QUALIFY was developed. Particular characteristics of QUALIFY include clear definitions of all criteria, consistent information as the basis of assessment and a standardized approach throughout the assessment process. QUALIFY comprises 20 criteria which are assigned to the three categories relevance, scientific soundness and feasibility. It was tested during the assessment of 55 indicators and served as the methodological basis for selecting those quality indicators that German hospitals are required to report publicly.

Background A specific risk model concerning mortality of patients undergoing isolated coronary artery bypass grafting (CABG) is developed based on the national quality benchmarking mandatory by law in Germany. Methods On the basis of the national data pool from 2004, a risk score model for patients undergoing isolated CABG was developed and finally adjusted with the data of 43,145 patients of the year 2008. Modeling was performed by logistic regression analysis. This risk model was validated with the 2007 data pool which comprised 45,569 patients. Results Observed in-hospital mortality after isolated CABG procedures was 3.0% in 2008. Hosmer–Lemeshow test p value was 0.189 and area under receiver operating characteristic curve was 0.826. Applying the German CABG score for 2007 resulted in an observed-to-expected mortality ratio of 1.01. Conclusion The German CABG score for in-hospital mortality is a risk score with proven validity for isolated CABG, developed by means of the patient population in Germany. It can be used for the assessment of patient risk groups and for interhospital benchmarking. We encourage other researchers to apply and validate this score in comparable health care systems.

OBJECTIVES: The aim of the study was to establish a scoring system to predict mortality in aortic valve procedures in adults [German Aortic Valve Score (German AV Score)] based upon the comprehensive data pool mandatory by law in Germany. METHODS: In 2008, 11 794 cases were documented who had either open aortic valve surgery or transcatheter aortic valve implantation (TAVI). In-hospital mortality was chosen as a binary outcome measure. Potential risk factors were identified on the basis of published scoring systems and clinical knowledge. First, each of these risk factors was tested in an univariate manner by Fisher’s exact test for significant influence on mortality. Then, a multiple logistic regression model with backward and forward selection was used. Calibration was ascertained by the Hosmer–Lemeshow method. In order to define the quality of discrimination, the area under the receiver operating characteristic (ROC) curve was calculated. RESULTS: In 11 147 of 11 794 cases (94.5%), a complete data set was available. In-hospital mortality was 3.7% for all patients, 3.4% in the surgical group (95% confidence interval 3.0–3.7%, n= 10 574) and 10.6% in the TAVI group (95% confidence interval 8.2–13.5%, n= 573). Based on multiple logistic regression, 15 risk factors with an influence on mortality were identified. Among them, age, body mass index and left ventricular function were categorized in three (body mass index, left ventricular dysfunction) or 6 subgroups (age). The Hosmer–Lemeshow method corroborated a valid concordance of predicted and observed mortality in 10 different risk groups. The area under the ROC curve with a value of 0.808 affirmed the quality of discrimination of the established scoring model. CONCLUSIONS: It is well known that a predictive model works best in the setting where it was developed; therefore, the German AV Score fits well to the patient population in Germany. It was designed for fair and reliable outcome evaluation. It allows comparison of predicted and observed mortality for conventional aortic valve surgery and transcatheter aortic valve implantation in low-, moderateand high-risk groups. Thus, it enables primarily a risk-adjusted benchmark of outcome and fosters the efforts for continuous improvement of quality in aortic valve procedures.

Summary Objectives This paper introduces the QUALIFY instrument as an indicator assessment method used to select quality indicators suitable for public disclosure in Germany. Methods Fifty-five hospital quality indicators previously approved in routine use were systematically tested for suitability in public disclosure. A multi-disciplinary expert team including patient representatives used the QUALIFY instrument to assess the methodological quality of these indicators in detailed respect to their purpose. The team applied 14 of the 20 QUALIFY criteria to each indicator, the minimum acceptance level for public reporting was determined in advance. Results Thirty one indicators from eleven clinical conditions fulfilled all fourteen methodological criteria required for national reporting. They include eleven outcome and twenty process indicators. Conclusions QUALIFY proved to be a useful tool for selecting quality indicators suitable for public disclosure and thus contributes substantially to proper information on German hospital quality. It ensures high transparency in a very sensitive context to all stakeholders.

Zusammenfassung Leitlinien konnen zur Verbesserung der Qualitat der medizinischen Versorgung in der Flache beitragen. Voraussetzung hierfur ist die erfolgreiche Implementierung der Empfehlungen aus Leitlinien in den Kreis der Anwender. Qualitatsindikatoren spielen im Leitlinienkontext eine herausragende Rolle. Einerseits werden uber Qualitatsindikatoren und deren Messung Ergebnisse generiert, bei deren Analyse im Rahmen der Versorgungsforschung Leitlinien weiterentwickelt und aktualisiert werden konnen. Sie liefern weiterhin Daten fur interne und externe Qualitatssicherungsmasnahmen, die die Implementierung der Leitlinien-Empfehlungen befordern und zusatzlich Informationen uber die reale Versorgungssituation und den Stand der Umsetzung von Leitlinienempfehlungen liefern konnen. Im Rahmen dieser Arbeit werden exemplarisch in zwei Leistungsbereichen der verpflichtenden externen Qualitatssicherung der BQS ausgewahlte Qualitatsindikatoren (praoperative Verweildauer bei Patienten mit Schenkelhalsfraktur, postoperatives Praparatrontgen bei Patienten mit Mammakarzinom) dahingehend untersucht, inwieweit die Empfehlungen der Leitlinie tatsachlich umgesetzt sind. Hierfur wurden aus dem Leistungsbereich „Mammachirurgie“ die Datensatze von 189.756 Patientinnen und aus dem Leistungsbereich „Huftgelenknahe Femurfraktur“ die Datensatze von 331.087 Patienten analysiert. Im Ergebnis zeigen sich erhebliche Unterschiede im Leitlinienimplementierungsverhalten. Der prozentuale Anteil an Rontgenaufnahmen des Praparats nach operativer Entfernung markierter Gewebslasionen stieg nach Publikation der deutschen S3-Leitlinie 2004 von initial 36,0% auf 83,9% im Jahr 2006 an und die Streubreite als Mas fur die Versorgungsvariabilitat reduzierte sich erheblich. Demgegenuber blieb der Anteil der Patienten mit Schenkelhalsfraktur, die nicht innerhalb von 48 Stunden nach stationarer Aufnahme operativ versorgt wurden, im Zeitverlauf stabil ohne wesentliche Verbesserungstendenz (2003 18,5%, 2006 16,0%). Eine hochwertige deutsche Leitlinie mit einer entsprechenden eindeutigen Empfehlung zur praoperativen Verweildauer existiert allerdings zurzeit noch nicht, so dass es sich bei dem Qualitatsindikator um die Uberprufung eines internationalen Leitlinienkonsenses handelt. BQS-Qualitatsindikatoren sind somit sehr gut geeignet, den Grad der Implementierung von Leitlinienempfehlungen messbar zu machen bzw. die Leitlinienentwicklung und -weiterentwicklung zu befordern.