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HEALTH TECHNOLOGY ASSESSMENT ON THE VOLUME-OUTCOME-RELATIONSHIP IN TOTAL HIP REPLACEMENT AND EFFECTS OF MINIMUM PROVIDER VOLUMES ON MEDICAL CARE IN GERMANY



Abstract

Aim: To assess the volume-outcome relationship of total hip replacement means of a Health Technology Assessment and to assess the effects of a minimum provider volume regulation on medical care in Germany

Methods: Electronic bibliographic databases, the reference lists of relevant articles and various health services research-related resources were searched and selected studies were assessed using defined quality criteria. Additionally, the implementation of these results and its consequences – excluding hospitals and/or surgeons that do not perform a defined number of operations a year from medical care – for the German Health System were calculated on routine data basis of the German Health insurance. Several different cut-off points (20 operations per year/50 operations per year) and the respective consequences on medical care were calculated.

Results: 26 publications, that comprise in a narrower sense with the volume-outcome-relationship of total hip replacement, were assessed. The results in literature concerning defined outcome parameters are inconsistent, but a general correlation between high volume and low complication rate could be identified. In contrast a cut-off point, that is able to discriminate “good” from “bad” health care could not be deduced from the results in the literature. Methodological aspects of the performed studies concerning volume-outcome relationship are to be considered, too, i.e. study design, statistics, endpoint definition. In Germany 1264 hospitals performed 150.000 total hip replacements in 2005. Implementing a regulation based on minimum provider volumes of 20/50 total hip replacements/year would lead to an exclusion of 216 (17%)/483 (38%)hospitals respectively from medical care. This would result in a reallocation of 2214 (1.4%)/11.478 (7,4%) patients/ year respectively.

Conclusion: Importance of HTA reports and expected consequences on health care will even increase in Germany especially regarding recent legal context. A correlation between high volume and low complication rate in total hip replacement could be identified by means of HTA. Keeping these results in mind and knowing that in consequence hospitals/surgeons that do not perform a defined number of operations a year will be excluded from medical care, the application of a minimum provider volume regulation in the German health care system must be performed very sensitve, because significant effects are to be expected.

Correspondence should be addressed to Ms Larissa Welti, Scientific Secretary, EFORT Central Office, Technoparkstrasse 1, CH-8005 Zürich, Switzerland