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Background: With the introduction of §115f SGB V, the prerequisites for "sector-equal remuneration" ('Hybrid DRG') have been created. In an impact analysis, we assigned inpatient gastroenterological endoscopic (GAEN) cases in a matrix of future hybrid DRG versus outpatient surgery (AOP) or inpatient treatment., Methods: In selected DRGs (G47B, G67A, G67B, G67C, G71Z, H41D, H41E) an allocation matrix of GAEN cases was created on medical grounds. For this purpose, service groups from the DGVS service catalog ('Leistungskatalog') were assigned to the groups: 'Hybrid-DRG', 'AOP' and 'Inpatient' by a group of experts based on the DGVS position paper. Cost data from the DGVS-DRG project for the 2022 data year from 36 InEK calculation hospitals with a total of 232,476 GAEN cases were evaluated., Results: 26 service groups from the DGVS service catalog were assigned to a "Hybrid-DRG", 24 to the "inpatient" group, and 12 to the "AOP" group. 7 performance groups were splitted "depending on the OPS code" and classified at this level. Cases with additional fees were excluded from a hybrid DRG because these cannot be agreed there.The cost analysis shows that services that are already in the AOP have a similar cost level to services that have been classified as 'Hybrid-DRG'. With the cost calculation, a cost level could be presented for the hybrid DRGs formed., Conclusion: Based on clearly defined structural, procedural and personnel requirements, services from suitable DRGs can be transferred to a hybrid DRG. Assigning services without the involvement of clinical experts seems extremely difficult. Case assignment based on arbitrary contextual factors increases complexity without demonstrably increasing the quality of the assignment and needs to be further developed. A cost analysis can be derived from the known inpatient costs and must serve as the basis for the 2025 Hybrid DRG catalog., Competing Interests: Keiner der Autoren erklärt einen Interessenkonflikt. Die inspiring-health GmbH (Markus Rathmayer, Wolfgang Heinlein) erfasst und berechnet auf Honorarbasis die §-21-KHEntgG-Datensätze der am DGVS-DRG-Projekt teilnehmenden Häuser., (Thieme. All rights reserved.)

Introduction:  The ambulantization of patient care that were previously provided as inpatient service is one of the goals of the current reform in the German healthcare system. In pulmonology, this particularly applies to endoscopic procedures. However, the real costs of endoscopic services, which form the basis for the calculation of a future so called hybrid DRG or in the AOP catalog, are unclear., Methods:  After selection of use cases including endoscopic procedures which can be performed on an outpatient basis by a committee of experts the appropriate DRGs were identified from the § 21-KHEntgG data for 2022 published by the Institute for the Hospital Remuneration System (InEK). The costs were calculated from the respective InEK cost matrix added by the calculated material costs., Results:  The use cases suitable for outpatient treatment were systematic endobronchial ultrasound (EBUS) with transbronchial needle aspiration (calculated costs € 2,175.60 without or € 3,315.60 including PET/CT), navigation-assisted bronchoscopy for peripheral lesions (depending on the methodology € 2,870.23 to €4,120.23) and diagnostic (flexible) bronchoscopy (€ 1,121.02)., Conclusion:  Outpatient treatment of endoscopic procedures that were previously performed inpatient is possible and necessary, and the costs calculated in this publication can form a reliable basis for appropriate reimbursement. Together with a structural quality that has been transformed to outpatient service and cross-sector cooperation, continued high-quality care for pneumological patients can be ensured., Competing Interests: Keiner der Autoren erklärte einen Interessenkonflikt. Die inspiring-health GmbH (M. Rathmayer, M. Tiefgraber, M. Wilke) hat als Berater für die Moderation der Arbeitsgruppensitzungen und die Durchführung der Kostenkalkulationen ein Beratungshonorar von der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V. erhalten., (Thieme. All rights reserved.)

Introduction: Whether inpatients with inflammatory bowel disease (IBD) are reimbursed in a cost-covering manner in German hospitals has not yet been investigated. In this context, the present study analyses the reimbursement situation (cost-revenue comparison) of IBD in German hospitals with regard to the complexity of the disease and the type of care., Methods: For this retrospective study, anonymized case data, including cost data from the InEK calculation (§ 21-4 KHEntgG) of the DRG project of the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) from 2019, were available. 3385 cases with IBD the as main diagnosis from 49 hospitals were analyzed. To investigate the impact of disease complexity on reimbursement, different variables were analyzed, including gastroenterological complications, infections, the reason for admission, and additional charges. To investigate possible center effects, hospitals were grouped by type of care, mostly defined by the number of beds., Results: The present study shows that all types of care can be classified as not cost-covering on average. The under-recovery is, on average, 10% (296 € absolute under-recovery) and varies between the types of care. Cases with higher complexity show a higher cost under-recovery than cases with lower complexity. At the DRG level, the analyzed costs of the three most common IBD DRGs for inlier patients are higher than the InEK costs; however, the difference is not significant. Nonetheless, cases with the admission reason transfer of specific DRGs bear significantly higher costs., Discussion: Our results show that CED is not reimbursed in a cost-covering manner. This is due to inadequate reimbursement for gastroenterological complications, infections, specific procedures, and emergency and transfer cases. Transfer cases bear significantly higher costs., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: The transfer of patient care and medical interventions that was previously provided on an inpatient basis to outpatient settings is a stated goal of health politics. It is unclear to what extent costs of an endoscopic procedure and the disease severity depend on the duration of inpatient treatment. We therefore examined whether endoscopic services for cases with a one-day length of stay (VWD) are comparably expensive to cases with a longer VWD., Methods: Outpatient services were selected from the DGVS service catalog. Day cases with exactly one such gastroenterological endoscopic (GAEN) service were compared with cases with VWD>1 day regarding their patient clinical complexity levels (PCCL) and mean costs. Data from the DGVS-DRG project with §21-KHEntgG cost data from a total of 57 hospitals from 2018 and 2019 served as the basis. Endoscopic costs were taken from cost center group 8 of the InEK cost matrix and plausibility checked., Results: A total of 122,514 cases with exactly one GAEN service were identified. Statistically equal costs were shown in 30 of 47 service groups. In 10 groups, the cost difference was not relevant (<10%). Cost differences >10% existed only for EGD with variceal therapy, insertion of a self-expanding prosthesis, dilatation/bougienage/exchange with PTC/PTCD in place, non-extensive ERCP, endoscopic ultrasound in the upper gastrointestinal tract, and colonoscopy with submucosal or full thickness resection, or foreign object removal. PCCL differed in all but one group., Conclusion: Gastroenterology endoscopy services provided as part of inpatient care but potentially performable on an outpatient basis are predominantly equally expensive for day cases as for patients with a length of stay greater than one day. The disease severity is lower. Calculated §21-KHEntgG cost data thus form a reliable basis for the calculation of appropriate reimbursement for hospital services to be provided as outpatient services under the AOP in the future., Competing Interests: Keiner der Autoren erklärt einen Interessenkonflikt. Die inspiring-health GmbH (Markus Rathmayer, Wolfgang Heinlein, Tobias Wagner, Michael Wilke) erfasst und berechnet auf Honorarbasis die §-21-KHEntgG-Datensätze der am DGVS-DRG-Projekt teilnehmenden Häuser., (Thieme. All rights reserved.)

Since the introduction of the G-DRG-system in Germany for the reimbursement of in-hospital patients in 2003 the Institute for the Hospital Remuneration System (InEK) annually determines case reimbursements for currently 1300 individual diagnosis-related groups (DRGs). These are based on the cost documentation of 200 representative hospitals, coopted by InEK (§ 21-KHEntG-dataset). Since DRGs represent cost averages, one half of German hospitals would be expected to report an annual income surplus, the other half a deficit. In spite of sustained cost reductions two thirds of public University Hospitals, but only 29 % of non-University hospitals, report annual deficits. The German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) has obtained the § 21-cost-dataset from 74 InEK-hospitals and 7 Mio anonymized cases since 2012 in order to appeal for individual DRG-corrections to InEK. In the current project this database was used to investigate whether the cost of care at University Hospitals is appropriately reflected in three representative DRGs and OPS codes (operation and procedure codes): Liver cirrhosis with hepatic encephalopathy, endoscopic procedure-tiers, and an endoscopic intervention after patient transfer from one hospital to another. The analysis reveals that the higher patient complexity, severity and cost at University Hospitals cannot be corrected by modification or further differentiation of individual DRGs within the existing G-DRG-system. Even in DRGs for which a differentiation would be possible and economically appropriate it is often not permitted. A further rise of the systematic deficit of German University Hospitals (currently 300 Mio. Euro annually) can only be prevented by introducing either a case-based DRG-System-Surcharge for University Hospitals or by separation of a University Hospital U-DRG-System from the general G-DRG-System., Competing Interests: Keiner der Autoren erklärt einen Interessenkonflikt. inspiring-health (MR und MW) erfasst und berechnet auf Honorarbasis die §-21-Datensätze der am DGVS-DRG-Projekt teilnehmenden Häuser., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction:  Hepatic encephalopathy (HE) represents a frequent complication of liver cirrhosis with negative effects on patients' lives. The prevalence of clinical HE is estimated to be between 30-45 %. Regardless of its clinical and prognostic relevance HE is considered to be underdiagnosed., Methods:  Beyond a systematic analysis of mortality of HE, we investigated the economic impact and reimbursement situation for HE in patients with liver cirrhosis in Germany. For the retrospective analysis, anonymized data (2011-2015) concerning expenses and diagnoses (§ 21-4 KHEntgG) were obtained from 74 participating hospitals of the Diagnosis Related Groups (DRG) Project of the German Gastroenterological Association (DGVS). Furthermore, results were compared with case data from all German hospitals provided by the German Federal Authority on Statistics (Statistische Bundesamt (Destatis), Wiesbaden)., Results:  In participating hospitals 59 093 cases with liver cirrhosis were identified of which 14.6 % were coded as having HE. Hospital mortality was threefold increased compared to cirrhosis-patients without HE (20.9 versus 7.5 %). Cases with cirrhosis as well as the proportion with HE increased over time. Compared to all patients with cirrhosis, reimbursement for HE patients produced a deficit (of up to 634 € for HE grade 4)., Discussion:  Mortality is threefold increased in patients with cirrhosis when an additional HE is diagnosed. Hospitals participating in the DGVS-DRG-project coded 2 % more HE cases among their cirrhosis cases than the rest of hospitals either because of a selection bias for greater disease severity or because of better coding quality. At present, reimbursement for HE patients on the basis of F-DRG-system produced a deficit., Competing Interests: M. Rathmayer, L. Koller und M. Wilke haben für die Analyse ein Beratungshonorar von der Fa. Norgine GmbH, Marburg erhalten. Gundling F., Labenz J. und Wedemeyer J. haben für Vortrags- und Beratungstätigkeit in der Vergangenheit Honorare von Norgine erhalten., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background  In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods  To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; § 21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results  Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion  For the first time this catalogue for endoscopic procedure-tiers, based on § 21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses., Competing Interests: Interessenkonflikt: M. Rathmayer, W. Heinlein, C. Reiß, M. Wilke haben als Berater bei der Durchführung der Kostenstudie und deren Auswertung ein Beratungshonorar von der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselerkrankungen e. V. erhalten., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Neoplastic changes (mild or high grade intraepithelial neoplasia (L- or HGIEN) or early cancer) in Barrett esophagus are treated with various methods. This study compares clinical-economical aspects of sole stepwise radical endoscopic resection (SRER) against combination treatment with EMR (Endoscopic mucosal resection) and RFA (radiofrequency ablation)., Material and Methods: Based on clinical data from a randomized controlled trial 1 we developed an economic model for costs of treatment according to the German Hospital Remuneration System (G-DRG). Our calculating incorporated initial treatment costs and the cost of treating complications (both paid via G-DRG)., Results: Medical and economically, the treatment with EMR + RFA advantages over sole SRER treatment 1. The successful complete resection or destruction of neoplastic intestinal metaplastic tissue is similar in both procedures. Acute complications (24 vs. 13 % in SRER EMR + RFA) and late complications (88 vs. 13 % in SRER EMR + RFA) are significantly more likely in sole SRER than in the EMR + RFA., Discussion: While SRER initially appears more cost-effective as a sole therapy, cost levels move significantly above EMR+RFA due to higher complication rates and following procedures costs. Overall, the costs of treatment was € 13 272.11 in the SRER group and € 11 389.33 in the EMR + RFA group. The EMR + RFA group thus achieved a cost advantage of € 1882.78. The study shows that the treatment of neoplastic Barrett esophagus with EMR + RFA is also appropriate in economic terms., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: New procedures in endoscopy take time to be incorporated in the German diagnosis-related groups (DRG) system. Depending on the extent of innovation and the costs, several pathways are possible., Methods: This article provides an overview of possible pathways to implement new procedures in the German DRG payment system. Additionally, we compare the results of 2 surveys on the system of New Diagnostic and Treatment Methods (Neue Untersuchungs- und Behandlungsmethoden; NUB). Furthermore, the pathways of 2 innovations in endoscopy are described in detail and compared with the possibilities within the legal framework., Results: The different pathways like NUB applications or DRG change requests and the underlying legal framework are described in detail. The results of a survey from 2007 on the daily practice of NUB funding in Germany show that the extent of innovations which receive a positive assessment (status 1) is 46% compared to 43.7% in a survey from 2007, and that 77% of the status 1 procedures (and drugs) can be negotiated into a payment - compared to 53% in the older survey., Conclusion: Medical scientific societies should be involved in this process from the beginning. Besides the importance for the hospital application process (81.3% of all medical controllers want to have society support), the regulatory bodies (e.g. DIMDI, InEK, G-BA) also appreciate scientific statements. Two examples show the pathways in detail. For radiofrequency ablation of Barrett's esophagus, the pathway of continuous change requests was chosen, while the endoluminal conduit for the treatment of type 2 diabetes was established as NUB payment.

Background: Clostridium difficile associated diarrhea (CDAD) is not only a increasing medical but also economical problem., Methods: Data from the DRG project group of the German society for digestive and metabolic diseases (DGVS) were analyzed for CDAD. Out of 430,875 cases from 37 German hospitals 2,767 cases were grouped by having CDAD either as primary (PD) or secondary diagnosis (SD; likely to be from a hospital source) in an initial or recurring hospital stay (RD). For comparison non-CDAD cases from the same hospitals from that year where matched using propensity score matching. As endpoints we defined LOS (length of stay), difference of LOS to national average LOS, total costs per case and difference between costs and revenue for all three groups., Results: Patients from the PD group (n = 817) showed a mean LOS of 11.2 days compared to 8.5 days for the control group, 4,132 € mean cost per case (536 € more than control) and a mean loss of -1,064 € per case compared to -636 €. In the SD group (n = 1,840) patients stayed in the hospital for 28.8 days (control: 18.1 days), had costs of 19,381 € (control: 13,082 €) and a loss of -3,442 € compared to -849 € in the control group. Recurring cases (RD; n = 110) showed a LOS of 37.3 days (control: 21.3 days), had even higher costs (20.755 € vs. 13,101 €) and higher losses (-4,196 € vs. -1,109 €)., Conclusion: By extrapolating these findings CDAD not only harms patients but generates a yearly cost burden of 464 million € for the German healthcare system including a loss of 197 million € for German hospitals. To the authors' opinion sufficient measures against CDAD should include pre hospital risk reduction programs, introduction of effective therapeutic and hygienic strategies in hospitals as well as improvements in documentation for these cases to support further developments of the German DRG system., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The German hospital reimbursement system (G-DRG) is incomplete for endoscopic interventions and fails to differentiate between complex and simple procedures. This is caused by outdated methods of personnel-cost allocation., Methods: To establish an up-to-date service catalogue 50 hospitals made their anonymized expense-budget data available to the German-Society-of-Gastroenterology (DGVS). 2.499.900 patient-datasets (2011-2013) were used to classify operation-and-procedure codes (OPS) into procedure-tiers (e.g. colonoscopy with biopsy/colonoscopy with stent-insertion). An expert panel ranked these tiers according to complexity and assigned estimates of physician time. From June to November 2014 exact time tracking data for a total 38.288 individual procedures were collected in 119 hospitals to validate this service catalogue., Results: In this three-step process a catalogue of 97 procedure-tiers was established that covers 99% of endoscopic interventions performed in German hospitals and assigned validated mean personnel-costs using gastroscopy as standard. Previously, diagnostic colonoscopy had a relative personnel-cost value of 1.13 (compared to gastroscopy 1.0) and rose to 2.16, whereas diagnostic ERCP increased from 1.7 to 3.62, more appropriately reflecting complexity. Complex procedures previously not catalogued were now included (e.g. gastric endoscopic submucosal dissection: 16.74)., Discussion: This novel service catalogue for GI-endoscopy almost completely covers all endoscopic procedures performed in German hospitals and assigns relative personnel-cost values based on actual physician time logs. It is to be included in the national coding recommendation and should replace all prior inventories for cost distribution. The catalogue will contribute to a more objective cost allocation and hospital reimbursement - at least until time tracking for endoscopy becomes mandatory., (© Georg Thieme Verlag KG Stuttgart · New York.)

Two methods are commonly used for the determination of transbranchial net fluxes of Na+ and Cl-: direct analysis of changes in ion concentrations in the external medium using flame spectrophotometry or titration (net flux method), and measurement of unidirectional ion fluxes by means of radioactive tracers (tracer method). When we applied both methods in the same preparation, the isolated perfused posterior gill of freshwater-acclimated Eriocheir sinensis, to determine net fluxes of Cl-, the results differed substantially. In artificial fresh water (AFW) containing NaCl, the net flux method yielded a net uptake, but the tracer method showed a net efflux of Cl-. The net uptake of Cl- was abolished in Na(+)-free AFW indicating that Cl- uptake is coupled with the uptake of Na+. Applying the tracer method, net efflux of Cl- remained almost unchanged in Na(+)-free AFW. This suggests the opposite mechanism, i.e. uncoupled uptake of Na+ and Cl-. The discrepancy in the results obviously depends on the method employed. Since the data obtained with the net flux method explain the osmoregulatory performance of crabs living in fresh water, we consider this method as appropriate for determining net transbranchial ion fluxes.

Ionic regulation by the gills of the freshwater-adapted Chinese crab, Eriocheir sinensis, was examined. The balance of uptake and loss of NaCl in crabs living in freshwater was established. Urine production was measured directly by cannulating the nephropores. Daily urinary loss of Na+ is equivalent to 16% of the haemolymph Na+ content and is substantially higher than that based on data from indirect measurements reported in the literature. Weight and area of anterior and posterior gills are proportional to body weight. The role of the gills in compensating urinary loss by uptake was determined by analysing changes in Na+ and Cl- concentrations in the external medium in which isolated perfused gills were suspended. In posterior gills, salt loss is quantitatively balanced by NaCl net uptake from an external concentration of 1.3 mmol l(-1) NaCl upwards. The transport constant (Kt) for half maximum saturation of net uptake and saturation of NaCl uptake are 1.5 mmol l(-1) and 4 mmol l(-1), respectively. In contrast to previous studies in which tracer fluxes or transepithelial short-circuit currents were determined, our method of direct ion determination shows that no net uptake of Na+ or Cl- occurs in posterior gills in the absence of the respective counter ion, or when uptake of one ion is blocked by a specific inhibitor. Net uptake of Na+ and Cl- was about equal. We conclude that the uptake of the two ions is coupled. The properties of the branchial ion uptake of E. sinensis correlates with the distribution of this crab in river systems.

1. Bath-application of L-glutamate to crayfish opener muscle causes depolarization and resistance changes which both increase with falling temperature. At temperatures above 15 degrees C there is usually a resistance increase, at lower temperatures the resistance is decreased. 2. Meso-gamma . gamma'-diaminosuberic acid-dihydrochloride (meso-di-GABA) and dl-diamino-nonanedicarboxylic acid dihydrochloride (C-9) were newly synthesized as potential glutamate blockers. 3. Meso-di-GABA (10(-4) to 10(-3)M) usually caused a significant increase (15 degrees C) or decrease (7 degrees C) of membrane resistance and slight depolarization. Excitatory junction potentials (ejps) were reversibly depressed or blocked while the effects of glutamate were potentiated. The depression or block of neuromuscular transmission was not prevented by picrotoxin or by concanavaline A. 4. C-9 (3 x 10(-4) M) depressed or blocked the effect of applied glutamate with little or no effect on ejps. 5. The results are best explained by assuming that bath-applied glutamate acts mainly on extrasynaptic receptors. Meso-di-GABA is assumed to block synaptic receptors and to activate non-synaptic receptors while C-9 seems to act mainly as a blocker of glutamate action on non-synaptic receptors.