Invited Commentary

Congenital Heart Surgery in Germany: The Current Situation in Quality of Care

This article is another important contribution dealing with quality of care in congenital heart surgery [1]. An adequate quality of care can only be guaranteed when three principles are adhered to: first, assurance of quality assessment (and interpretation); second, assurance of sustainable structures (also economically); and third, continued training.

The first two are dealt with in the manuscript. The authors analyzed over 2000 procedures. The Aristotle basic score, corresponding hospital survival rates and related observed surgical performance were estimated. Observed performance divided by expected performance was called the “standardized ratio of performance”. We are provided with a detailed overview of Sankt Augustin's institutional practice over the years. In conclusion, this approach allows for an accurate quality evaluation for any congenital heart surgery program.

This is a very important message. The tools exist, but unfortunately not all German institutions make use of them [2]. Even though the German Society for Thoracic and Cardiovascular Surgery together with its working group on “Congenital and Paediatric Heart Surgery” urges all institutions to participate in quality assurance [3], this still does not happen on a nationwide basis. In line with this, the Federal Joint Committee (G‐BA, www.g-ba.de) [4] finally issued regulations on structures and quality assurance in congenital heart surgery in February 2010.

The third pillar, ensuring education and training in these often complex entities, ought to be the target of any nationwide incentive to provide adequate quality of care. The described approach of strict quality assessment allows the monitoring of care in individual centers over time. Individual surgeons' case loads, their complexity and results must be evaluated. Only then can adequately sized institutions ensure a safe program and enrol trainees on a regular basis.

In summary, there is a growing need for transparency with regard to quality assurance. A continuous and comprehensive analysis of data ought to be compulsory. Institutional and multi-institutional results for the surgical treatment of patients with congenital heart defects must be assessed and interpreted in a comparable manner.

References

• 1 Photiadis J, Sinzobahamvya N, Arenz C et al. Congenital heart surgery: expected versus observed surgical performance according to the Aristotle complexity score.  Thorac Cardiov Surg. 2011;  59 268-273
• 2 Schreiber C. Quality assurance in congenital heart surgery.  Dtsch Med Wochenschr. 2009;  134 S220-S221
• 3 DGTHG . Struktur chirurgischer Einheiten zur Behandlung angeborener Herzfehler.  Thorac Cardiovasc Surg. 2006;  54 73-77
• 4 Gemeinsamer Bundesausschuss .Richtlinie des Gemeinsamen Bundesausschusses über Maßnahmen zur Qualitätssicherung der herzchirurgischen Versorgung bei Kindern und Jugendlichen gemäß § 137 Absatz 1 Nummer 2 SGB V (Richtlinie zur Kinderherzchirurgie). Online: http://www.g-ba.de/downloads/62-492-472/RL_Kinderherzchirurgie_2010-11-11.pdf [accessed 1.6.2011]