Schlüsselwörter
DRG - Qualitätssicherung - Kodierung - DGGG - MDC - Adaptation
Introduction
As of 2004 a large portion of the provided inpatient hospital services must
obligatorily be accounted for via the DRG fixed relative weights. Since the
introduction of the first G-DRG system in 2003 the G-DRG system, the settlement
rules (FPV), the German coding standards (DKR) and underlying basic classification
systems for diagnoses (ICD-10-GM) and procedures (OPS) have been annually developed
further. In parallel the basis for calculation – the data upon which the yearly
further developments of the G-DRG system are based – has been continuously improved.
The resultant G-DRG system has only little similarity with the originally copied
Australian model and is now a world leader with regard to its differentiating
ability and the thus realised fair and just distribution [1]. The development of the G-DRG system lies in the hands of the
Institute for Reimbursement Systems in Hospitals (Institut für das Entgeltsystem im
Krankenhaus, InEK), an organ of the self-governing partner in health-care services.
On the other hand, the classification systems ICD-10-GM and OPS are cared for by the
German Institute of Medical Documentation and Information (Deutsches Institut für
Medizinische Dokumentation und Information, DIMDI). The DIMDI is an agency under the
auspices of the Ministry of Health. Both seek and use the expertise of the users in
the development process by a so called “structured dialogue” [2], [3]. Without participation of the users the
possibilities for further development of the reimbursement system in Germany would
be limited. Because of the increasing complexity of the G-DRG system, however, it
will be increasingly difficult for the professional medical societies to develop
concrete modification proposals in the framework of the structured dialogue without
external help. The still very high implementation rate of one third of the
modification proposals for the G-DRG system on the other hand emphasises the
relevance and necessity of the “structured dialogue” [1], [4], [5].
In 2012 the German Society for Gynaecology and Obstetrics (Deutsche Gesellschaft für
Gynäkologie und Geburtshilfe, DGGG) decided in cooperation with the DRG Research
Group in Münster to initiate a DRG evaluation project. The aim of the project was
to
develop on the basis of a comprehensive analysis targeted modification proposals to
improve the representation of the specialty in the G-DRG system and to incorporate
them in the “structured dialogue”.
Method
In February 2012 and July 2012 a total of 440 hospitals with gynaecological
department were approached twice by post concerning support of the project. 18
hospitals agreed to support the project financially, of these a couple were not
allowed by their management to supply data. Altogether the cost and performance data
of 16 hospitals for the year 2011 ([Table 1]) were
collected and evaluated. Besides five university hospitals a further 11 hospitals
supplied data. The cost and performance data corresponded to the data that were
supplied to the InEK [6]. Two further hospitals ([Table 2]) could only supply performance data because they
did not supply information for the InEK calculation procedures and thus did not have
any cost data available.
Table 1 Hospitals that were able to supply cost and
performance data for the DRG evaluation project.
|
Hospital
|
|
Pius Hospital Oldenburg
|
|
University Hospital Erlangen
|
|
Medical University Hannover
|
|
University Hospital Schleswig-Holstein Campus Kiel
|
|
Clinic St. Georg gGmbH Leipzig
|
|
DRK Hospital Chemnitz-Rabenstein
|
|
University of Regensburg Caritas Hospital St. Josef
|
|
Marien Hospital Herne
|
|
Clinic Coburg gGmbH
|
|
Regional Hospital Starnberg GmbH
|
|
Clinic Oldenburg gGmbH
|
|
Marien Hospital Bottrop gGmbH
|
|
Westpfalz Clinic GmbH Kaiserslautern
|
|
Hospital St. Joseph Stiftung Dresden
|
|
University Hospital Tübingen
|
|
Municipal Hospital Brandenburg GmbH
|
Table 2 Hospitals that were only able to supply performance
data for the DRG evaluation project.
|
Hospital
|
|
University Hospital Greifswald
|
|
University Hospital Aachen
|
Data Plausibility Checks
Coding errors or locally widely varying coding practices or expertise style among
the
controlling services of the cost-bearers (e.g., MDK) lead to variations in DRG
assignments. On analysis of the DRG representations, deviations in DRG assignments
could suggest not valid cost differences or smooth out existing cost differences.
Accordingly, data transfer was followed by a comprehensive check of plausibility of
coding with the help of over 300 for the specific specialty choosen validation
rules. Emphasis was placed hereby on billing-relevant attributes (principal
diagnosis, special additional diagnoses, OPS codes or, respectively, their
combinations). In addition, plausibility checks were applied to attributes that do
not yet have any relevance for grouping in the G-DRG system or as an additional
reimbursement but which, however, are assigned a high potential for future
relevance. Thus, for example, on the basis of the admission date and the procedure
date for delivery, a comparison was made with the coded OPS code of the class 9-280
(stationary treatment prior to delivery in the same admission session). In
cooperation with the hospitals, numerous coding errors could be corrected and the
coding unified. Finally, only a very low number of cases (< 0.5 %) – especially
due to conspicuities in the cost data – had to be excluded from the further
evaluation.
Ultimately, 52 285 completely inpatient treatment cases (excluding the newly born
babies and cases with services from private doctors or midwives) from 16 hospitals
were available for an analysis of cost homogeneity of the G-DRG. Since cost and
performance data of the DRG systems exist only for inpatient cases, no conclusions
on outpatient reimbursement structures were possible from this project. The cases
originating from the year 2011 were grouped into the systematics of the G-DRG system
2013 with the help of a so-called transition grouper. Thus it was possible to
compare these costs with the cost values of the G-DRG cost calculation by the InEK.
The 52 285 cases were distributed among a total of 416 G-DRGs. However, the emphasis
of the evaluation was directed to G-DRGs of the 3 major diagnostic categories (MDCs)
of relevance for the specialty:
-
09: Diseases and disorders of the skin, subcutaneous tissue and breast
-
13: Diseases and disorders of the female reproductive system
-
14: Pregnancy, childbirth and the puerperium
For special analyses additional specific DGRs of the following MDCs were also taken
into consideration:
-
06: Diseases and disorders of the digestive system (→ e.g., endometriosis,
adhesiolyses)
-
11: Diseases and disorders of the kidney and urinary tract (→ incontinence
surgery)
-
21B: Injuries, poisoning and toxic effects of drugs (→ e.g., breast surgery,
prophylactic operations)
The case numbers available for analyses of the relevant individual DRGs included to
an appreciable extent the data that were available to the InEK for calculation of
the G-DRG system 2013. Thus, the proportion of inliers (duration of stay between the
lower and upper trim points for a specific G-DRG) of the project in the InEK
calculation sample in the for the specialty exclusive MDC14 (Pregnancy, childbirth
and the puerperium) for example, amounted to between 10.6 % (G-DRG O63Z) and 52.8 %
(G-DRG O02A). For childbirth DRGs it was a minimum of 22.4 % for uncomplicated
vaginal delivery (G-DRG O60D). With increasing complexity of the needed services the
case proportion in the InEK calculation sample also increased. Thus there was a
sufficiently large number of cases available for in-depth analyses with a slight
over-representation of services from maximum and specialist care-givers.
For the analysis – besides the inlier cases that areexclusively used in the
development of the G-DRG system – the so-called outliers were also taken into
consideration. Low outliers (length of stay less than the lower trim point for a
specific G-DRG) play an important role in gynaecology and obstetrics. Accordingly,
in some relevant G-DRGs of the specialty, the great majority of the cases have
lengths of stay below the lower trim point (for example, G-DRGs N09B “other
interventions on vagina, cervix and vulva”, N10Z “diagnostic curettage,
hysteroscopy, sterilisation, pertubation”, O40Z “abortion with dilatation und
curettage, aspiration curettage or hysterectomy” or O63Z “abortion without
dilatation and curettage, aspiration curettage or hysterotomy”). Patients with a
longer duration of stay are also highly relevant. High outliers (patients with a
length of stay longer than the upper trim point of a specific G-DRG) are, in order
to create incentives, deliberately and systematically under-financed. However, if
a
longer duration of stay is systematically associated with a justifiable special and
necessary service (for example, prevention of premature birth), this is not a sign
for inefficient processes. Hospitals providing these services, however, may be
penalised in spite of an economic provision of health care. Accordingly, particular
attention was directed to such case collectives. Cases transferred to and from
hospitals which may also be assigned as outliers do not quantitatively play a
significant role. Only in those cases of postpartum maternal care (mainly transfers
with a newborn requiring treatment), do appreciable case numbers arise that were
analysed in detail.
In the analysis, apart from the duration of hospital stay, above all the costs were
taken into consideration. After adjustment of the costs for expenses covered by
additional reimbursements, the total costs were divided into so-called costs for the
key service and the remaining differential costs that are regarded sensible to the
duration of stay for further in-depth analysis. Costs for the key service and
differential costs are constructs that are relevant for the development of the G-DRG
system and for determining the increases and reductions for outliers [7]. By division of the differential costs by the duration
of stay (differential costs/days in hospital) a “daily cost rate” could be
determined. When required a break-down and consideration according to personnel
costs, expenditures on material, and infrastructure costs or even an assessment at
the level of individual fields of the InEK cost matrix was performed. In addition,
revenues in the G-DRG system can be simulated. For this the German state-wide base
rate 2013 (3068.37 €) was used. However, costs from the year 2011 cannot be
methodologically related to revenues of the year 2013 without reservations. Even so
only this analysis offers the opportunity – under consideration of the limitations
–
to estimate the extent of underfinancing for the high outliers.
For the identification of conspicuities in the performance of services, which may
possibly require an altered or separate representation in the G-DRG system, a
comparison was made not only with the case collective of the InEK but also an
inter-hospital comparison was undertaken. The comparison with the case collective
of
the InEK served mainly to analyse the representation of the entire specialty. If
this showed that the project collective exhibited a higher cost value or longer
duration of stay than that in the InEK collective, the respective reasons were
sought. On the one hand this could be due to the composition (e.g., relative
specialisation) of the project sample or to an inappropriate condensation of
services of different medical specialties at the level of the individual G-DRG. The
comparison with the InEK collective is, however, always limited by the fact that,
with the exception of the outlier quota, as yet only the calculation data for the
inliers have been published. Only with the so-called implicated one-day-stay DRGs
is
it possible to derive the total costs in the InEK calculation sample from the value
relation of the current G-DRG catalogue. Thus, a supplementary comparison of the
total cost for short duration patients by means of the implicated one-day-stay DRGs
was possible. The inter-hospital comparison, i.e., the juxtaposition of the values
from the individual project clinics would make possible the identification of
special characteristics in the services provided within the peer group. In part in
direct communication with the project clinics it was attempted to extract the
necessities for a system adaptation from the unspecific heterogeneity of the
services provided.
By means of an analysis of clinical profiles [8] attributes
(especially ICD and OPS codes) were sought that could serve as appropriate
representations of the services. Thereby the average cost values of cases possessing
the respective attribute were compared with the costs and the duration of hospital
stay for the entire group. The entire group was considered to be the inliers/all
cases of a G-DRG but also higher aggregations (for example adjacent DRGs).
In addition, the existing DRG split criteria, DRG condensations and individual DRG
definition tables were checked for their appropriateness. Because of the broad
spread of many clinical case collectives in gynaecology and obstetrics over various
G-DRGs, DRG-overlapping evaluations and simulations had to be performed frequently.
Supplementary analyses were undertaken on the basis of concrete leads from a DGGG
working group.
On the basis of the described methodology, numerous adaptation options have been
identified. Apart from classical changes of DRG definitions, these are also
concerned with more complex reconstructions in the G-DRG system. In addition,
numerous hints were found as to where changes/supplements to the coding standards
and classification systems (ICD-10-GM und OPS) could contribute to a more
appropriate representation. The adaptation options derived from the data analysis
were then presented to the DGGG working group and discussed in detail. This was to
ensure that the found conspicuities were not based on artefacts and that differences
in expenditure could be understood from the clinical point of view. Furthermore,
consultations were held on the incentives for a modified representation of the
services in the G-DRG system. The aim was to submit only those adaptation proposals
that could sustainably lead to a better representation of the services and to set
as
few false incentives as possible. Apart from false incentives for case selection and
service control, the effects with regard to medically not needed documentation and
the potential for conflict in the framework of the auditing process by the cost
bearer were taken into consideration. In particular the mentioned aspects were taken
into account when there was a choice of solutions to a constellation of problems.
Solution options associated with an expected high expenditure of administrative
effort were given low priorities.
Thus, care was taken to present solution options that could reduce false incentives.
What does this mean? The delivery of a premature baby often has a better
reimbursement than a birth after the 38th week of pregnancy. Because of the shorter
prepartum hospitalisation, the costs for the inpatient stay are lower. The legal
prerequisites and minimum patient numbers for a perinatal centre have not yet been
taken into account in these considerations. The ethical professional view must stand
above any financial pressure as the supreme good and so it is never justifiable in
such situations to initiate delivery earlier than is necessary for purely financial
gain.
Altogether very little time was available in that yearʼs DRG development cycle for
the analysis, discussion and formulation of modification proposals. Although the
InEK presented the preliminary version of the G-DRG system 2013 at the end of August
2012 to the self-governing bodies as planned, agreement at the level of the
self-governing bodies again proved to be difficult. Even so and in contrast to the
previous year when the Ministry of Health had to carry out a substitute performance,
an agreement on the G-DRG system was achieved. On 19. 10. 2012 – approximately 4
weeks later than in the years before – the systematics of the new G-DRG system were
published and the software for transfer of the data from the year 2011 into the
G-DRG system 2013 was certified [9]. On 28. 11. 2012 the
final version of the G-DRG system 2013, which also took the ICD and OPS codes valid
for 2013 into account was published. This version was especially important for the
analysis of the MDC 09 data because considerable changes in the OPS coding of
senological interventions were made between 2011 and 2013. On 19. 12. 2012 the final
report of the InEK and the report browser 2011/2013 with the cost and performance
data of the InEK calculation sample, which was necessary for the differentiated
evaluation, was published [1].
Results
Modification proposals had to be submitted to the DIMDI in suitable form by at the
latest 28. 02. 2013 and those to the InEK by 31. 03. 2013 at the latest. A number
of
in part very complex modification proposals as well as adaptation options containing
numerous partial proposals was selected and submitted on time by the DGGG ([Table 3]). The respective documents are available on
request from the authors.
Table 3 Summary of the submitted modification
proposals.
|
DIMDI
|
|
|
3
|
|
|
1
|
|
InEK
|
|
|
4
|
|
|
9
|
|
|
1
|
|
|
6
|
|
|
24
|
The modification proposals for the further development of ICD-10-GM concerned, among
others:
-
The establishment of specific ICD codes for infections or other complications
due to breast prostheses or implants. The current coding by way of organ
unspecific ICD codes leads in connection with DKR 1205 d to the grouping of
the cases in the (unspecific) collection DRGs of MDC 21B (“Injuries,
poisoning and toxic effects of drugs”), which does not represent the
performance adequately (specifically).
-
The establishment of specific ICD codes for the care of the mother in case of
(suspected) malformation of the cardiovascular system or, respectively, the
respiratory organs of the foetus. Here also it is seen that an adequate
representation including contingency costs for complicated cases is not
achieved with the current (unspecific) codes.
-
The establishment of a specific ICD code for the tubular breast and
clarification of the coding with regard to Polandʼs syndrome.
The application for an FAQ entry addresses the coding of plastic reconstruction in
connection with a myoma enucleation. The representation in the OPS catalogue and in
the G-DRG system at first appears to be adequate. However, in many places – possibly
on the basis of the undifferentiated coding recommendation No. 382 of the social
medicine expert group (SEG) 4 of the MDK dated 12. 04. 2011 (www.mdk.de/1534.htm)
–
an adequate coding and DRG representation is not realised. At issue here – and this
is shown by individual discussions with the MDK – is to what extent a reconstruction
of the uterus is part (“procedure component”) of the OPS code for myoma enucleation.
The working group of the DGGG is of the opinion that there are indeed myoma
enucleations for which an extensive reconstruction of the uterus (e.g., large myomas
with a wide intramural extension) is not a part (“procedure component”) of the OPS
code for myoma enucleation. Other myoma enucleations for which no reconstruction is
required (subserous myomas with only a small myometral defect, for which among
others, merely an adaptation or coagulation is needed) are adequately represented
by
the corresponding OPS code.
The modification proposals for further development of the coding standards concern
among others:
-
Clarification and lifting of the contradictions in the choice of principal
diagnosis in obstetrics (DKR 1505a, 1506f, 1511a, 1512d and 1519e) [10]
-
Acceptance of the multiple classification with ICD codes for the organ
chapter in obstetrics (DKR 1510b)
-
Clarification in the choice of principal diagnosis for infections or other
complications for breast prostheses or implants (DKR 1205d),
additional/corresponding modification options to the DIMDI (see above)
-
Establishment of a new DKR for the choice of principal diagnosis for
prophylactic operations (e.g., women with BRCA 1/BRCA 2 mutations) and
deletion of the paragraph in DKR 1205d concerning subcutaneous prophylactic
breast amputation
The modification proposals to MDC 09 concern among others:
-
Representation of a combination of multiple interventions on the breast and
female sexual organs in MDC 09
-
Representation of breast reduction surgery (currently G-DRG J06Z, J24B)
-
Separation of senological cases from the dermatology-dominated adjacent DRG
J11
-
Representation of plastic reconstruction with pedicled skin-muscle grafts
(myocutaneous flaps), with/without prosthesis implantation (currently G-DRG
J14B, J24B)
-
Representation of bilateral prosthesis implantations (currently G-DRG J16Z)
and annulment of the condensation with radiotherapy cases,
-
Representation of the various mastectomy procedures (currently adjacent DRG
J24)
-
Representation of the implantation of a skin expander (currently G-DRGs J23Z,
J16Z, J06Z and J24B)
-
Procedure split of G-DRG J25Z or, respectively, case shift of special
procedure combinations in the adjacent DRG J07
Analyses and modification proposals for MDC 09 have been made difficult by the fact
that between 2011 and 2013 the procedure coding in senology was fundamentally
changed. The coding for the data year 2011 could thus not be automatically
transferred to the systematics of the OPS catalogue 2013.
The modification proposals for MDC 11 address the representation of paraurethral
injection treatment with Bulkamid (currently G-DRG L17B). Altogether it was seen
that ambiguities in the coding of the principal diagnosis frequently occurred within
the framework of incontinence treatment. It should be mentioned that, according to
DKR D002f, when a pathology is specifically treated the pathology itself and not the
symptomatics is to be coded as the principal diagnosis. The disputed coding
recommendation No. 57 of the SEG 4 of the MDK, which contradicts DKR D002f and leads
to an inappropriate DRG grouping, should not be employed for coding in gynaecology
and obstetrics. Many cases with a colporrhaphy and other operations are assigned on
the basis of a wrong choice of the principal diagnosis to the G-DRGs of MDC 11 which
are under-reimbursed for this service. With a correct coding an appropriate
representation – mostly in G-DRG N06Z – would be achieved.
The modification proposals for MDC 13 concern among others:
-
Assignment of all manifestations of endometriosis to MDC 13
-
Complex restructuring of the unspecific adjacent DRG N11 that collects cases
that cannot be assigned to more specific DRGs to avoid underpayment of
additional services (numerous other G-DRGs of MDC 13 affected)
-
Representation of cases with the principal diagnosis of a malignancy and
avoidance of underpayment for additional services (numerous other G-DRGs of
MDC 13 affected)
-
Representation of “simple” hysterectomies in connection with
lymphadenectomies (currently adjacent DRG N03)
-
Decondensation of interventions on the uterus and adnexa in cases with
malignancy on other organs as well as reconstructions of vagina and vulva
(currently G-DRG N03A)
-
Representation of the various forms of ureterolysis
The modification proposals for MDC 14 concern among others:
-
Financing of longer prepartum hospital stays to avoid a premature birth
(currently adjacent DRGs O01, O02 and O60)
-
Condensation of the adjacent DRGs for vaginal delivery (O02 and O60) and
establishment of a new split construct
-
Representation of instrumented vaginal deliveries (currently adjacent DRGs
O02 and O60)
-
Elimination of the “error-DRG” 962Z and annulation of DKR 1506f
-
Representation of special complicating diagnoses and procedures in connection
with delivery in numerous individual proposals (e.g., coagulopathies,
complications, uterus extirpations)
-
Complex restructuring of prepartum admissions and pregnancies with abortive
outcomes (currently adjacent DRGs O03, O05, O06, O40, O62, O63, O64 and
O65)
-
Consideration of special complicating diagnoses (e.g., infections, mental
disorders) in prepartum admissions (currently adjacent DRG O65)
-
Diagnoses split for G-DRG O61Z to separate cases with complications and
co-hospitalisation due a new-born baby requiring treatment in postpartum
admissions
Furthermore, an expert opinion about the problems in the regulation of maternity
hospitalisation according to § 24 f SGB V or § 197 RVO instead of § 39 SGB V
(hospitals treatment) was formulated. Because of these deviating regulations, the
use of many other provisions that are based on § 39 SGB V is made difficult. This
concerns, for example, the rules for the six-week period and administration fee in
the auditing process by the health insurances (§ 275 para. 1c SGB V).
Discussion
To what extent the submitted modification proposals will be realised in the sense
of
the DGGG remains to be seen. Already due to their sheer number and complexity it is
doubtful that a comprehensive analysis and processing by the InEK will be possible
within one adaptation cycle. Ultimately, it remains open, even with sufficient time,
whether or not problems and solution proposals – identified on the basis of the not
always representative project data from the year 2011 – can be reproduced also for
the calculation collective of the InEK in the G-DRG system 2014 (costs and
performance data for 2012). By plausibility verification of the data-driven,
achieved hypotheses with the help of the working group of the DGGG, this does,
however, seem possible for most of the modification proposals. Even so it must be
considered that many of the modification options may interact mutually and that the
processing (prioritisation) of the submitted modification proposals may have an
impact on the probability of their realisation. In addition, other users and
institutions may also submit modification proposals. Furthermore, general system
changes such as, for example, an adaptation of the degree of severity matrix for
additional diagnoses (so-called CCL matrix) or the hierarchic arrangement of the DRG
requests in the algorithm can have a considerable impact on the composition of the
affected G-DRGs (especially in MDC 13). Last but not least, modification proposals
can, in spite of apparent false representations and consequent solution proposals,
fail when no agreement on a solution can be achieved among the self-governing
bodies. This practically always affects modification proposals on coding guidelines
and on the establishment of additional payments that do not refer to services that
have already received interim financing as new examination and treatment methods
(NUB). Nevertheless, modification proposals to the above-mentioned problems can
still be meaningful. After the self-governing bodies had obliged the user and
especially the professional societies to cooperate by means of the “structured
dialogue” in the further development of the G-DRG systems it was demonstrated that
representation problems could be identified and constructive solutions sought. The
responsibility for weak representations and inappropriate distributions then goes
back to the self-governing bodies. The professional societies can then strongly and
with high legitimation demand a solution for representation problems [11].
On the whole, it must be considered that within the framework of the DRG evaluation
project it is only possible to highlight solution options that impact on the fair
and just distribution of resources. Mostly an improved representation of the
services in the G-DRG system leads “only” to a redistribution within a peer group.
This means that there is on the one side a “winner” but on the other side there will
also be a “loser” within the specialty group. On the basis of the strictly
data-based adaptation of the G-DRG system, however, the “loser” had ultimately
always been the (unjust) “winner” of a previously undifferentiated representation.
Due to the adaptation the “winner” merely receives that portion of the cake to which
he/she is entitled in a fair and just allocation [12].
Outlook
The G-DRG-system is mainly used as an instrument to set incentives for an economic
performance of services and to distribute the limited financial resources as
appropriately as possible among the service providers. Although the financial
pressure that nowadays burdens all hospitals is frequently ascribed to the G-DRG
system, this will become less and less due to the G-DRG system with the increasing
equitable distribution of resources [13]. Increasingly
serious are the lack of refinancing of the increasing costs in the hospitals and the
reduced investments by the states. In contrast to the equitable distribution, the
underlying questions that concern the (solidary) financing of hospital services can
only be solved at the political level.
Nevertheless hospitals are forced to respond to the increasing financial pressure.
It
is thus advisable to have knowledge of oneʼs own position in the competitive market.
Accordingly, the hospitals participating in the DRG evaluation project received a
comprehensive benchmarking report that allows a comparison of the services provided
at the DRG level with the project group and with German nation-wide comparative
data. Now that, due to the complexity of the G-DRG system, the specialty-specific
services are scattered over numerous different G-DRGs, a benchmarking report at the
level of the clinical services groups was provided [14], [15]. With this report the provision of
services can be compared on the basis of more or less predictable or, respectively,
strategic development of accessible clinical case collectives. The comparison on the
basis of clinical service groups offers the possibility to identify the strengths
and weaknesses of oneʼs own hospital and to deduce specific needs for action or
development potentials.
The new G-DRG system 2014 will probably be available for analysis at the end of 2013.
As soon as the grouper software becomes available, quantitative estimations will be
possible as to what effects the further development will have for the specialty and
its subspecialties. The authors will then report on the relevant changes.
Acknowledgements
This project was made possible by the financial support of the following hospitals
(towns/cities in alphabetical order). Some of the hospitals were not allowed by
their administrations to supply data to the project:
-
University Hospital Aachen, Aachen
-
Municipal Hospital Brandenburg GmbH, Brandenburg
-
DRK Hospital Chemnitz-Rabenstein, Chemnitz
-
Clinic Coburg gGmbH, Coburg
-
Hospital St. Joseph-Stiftung Dresden, Dresden
-
University Hospital Erlangen, Erlangen
-
University Hospital Greifswald, Greifswald
-
Medical Hospital Hanover, Hanover
-
Ruprecht-Karls-University Heidelberg, Universitätsklinik, Heidelberg
-
Marien Hospital Herne, Herne
-
University Hospital Schleswig-Holstein Campus Kiel, Kiel
-
Clinic St. Georg gGmbH, Leipzig
-
Clinic the University of Munich, Campus Innenstadt, München
-
Dietrich-Bonhoeffer Clinic Neubrandenburg, Neubrandenburg
-
Clinic Oldenburg gGmbH, Oldenburg
-
University of Regensburg, Caritas Hospital St. Josef, Regensburg
-
University Gynaecological Clinic Tübingen, Tübingen
-
University Hospital Ulm, Ulm
