Un espacio de posibilidades

Index value

4. Selected indicators 53

Context

Hospital day cases (“Stundenfälle”) is a technical term describ- ing patients who have been admitted to a hospital and are dis- charged, are transferred to another hospital, or die on the same day (Stat. Bundesamt 2011a). In Germany, medical care should follow the principle “outpatient trumps inpatient care.” A full inpatient admission is justified only if medical care cannot be delivered on an outpatient or partial inpatient basis. Full inpa- tient hospital services are remunerated differently than other services, such as ambulatory surgery, that are part of the out- patient service spectrum. Reimbursement of full inpatient treat- ment depends among factors such as the diagnosis (or diagno- ses), procedures performed, and length of stay. Day cases can be billed as a full inpatient day and thus ordinarily tend to gen- erate higher payment than the corresponding fee for outpa- tient care.

In 2009, German hospitals treated more than 516,000 patients as day cases in line with the above definition; this corresponds to just under 3% of all hospital cases. The number of day cases increased between 2008 and 2009 by 1.8%, somewhat more than the overall number of hospital cases (up by 1.6%) (Stat. Bundesamt 2011a). The principal diagnoses for day cases cover a broad spectrum of diseases. In 2009, the most common rea- sons for treatment were diseases of the circulatory system at 14.9% (about 78,000 cases); mental and behavioral disorders at 14.4% (about 78,000 cases, including about 49,000 cases alco- hol-related); and injuries, poisoning, and other consequences of external forces at 11.8% (Stat. Bundesamt 2011a, own cal- culations).

In this analysis, day cases are cleared of cases referred else- where on the day of admission, deaths on the same day, and infants less than one year old. Also excluded are day cases in psychiatric, psychosomatic, and/or psychotherapeutic special- ist departments. For the years 2007 to 2009, the total remain- ing number of day cases averaged about 330,000 per year.

Magnitude of regional variation

The number of day cases billed in the district with the highest index value was 9.7 times the number in the district with the lowest index value. When the 20 districts at each extreme are excluded, the range drops to 3.2-fold (0.5 to 1.7). Regionally, a clustering of day cases can be observed in many regions of Bavaria and some districts in Hessen, in the south of Lower Saxony, and in the west of Schleswig-Holstein. Day cases tend to be below the national average in the new federal states, but also in some districts of all the other federal states.

Hypotheses and options for action

At the interface between outpatient and inpatient care – espe- cially in emergency care – it sometimes happens that a full inpatient admission seems necessary and yet the patient can be discharged that same day. For example, the patient’s health status may unexpectedly improve within a short time; diagnostic results may not confirm the initially suspected

condition; or patients may refuse to stay in hospital (e.g., with alcohol abuse). Hospitals can bill such cases as day cases. Hypotheses for the strong regional variations in day cases take a number of factors into consideration. For cases in the interface between outpatient and inpatient care, hospitals have several billing options. They can consider classifying treatment as a day case, but also as emergency care or as pre- admission treatment without subsequent hospitalization. The assignment of a case to a billing category may well be influ- enced by the incentives for each option – that is, the financial consequences, but also how closely such invoices are scruti- nized by sickness funds (or by the Medical Review Board of the Statutory Health Insurance Funds).

Under certain circumstances, deliberate avoidance of same- calendar-date discharges can reduce the number of day cases. Incentives are subject to regional variation, because different remuneration regulations and monitoring systems apply. It may also be assumed that hospitals and sickness funds have agreed to specific protocols for the classification of borderline cases and that these could contribute to the marked regional variations in the number of day cases.

However, regional differences in the frequency of day cases can also be influenced by ambulatory care structures. It is plausible to assume that some patients who become hospital “day cases” could have been treated entirely as outpatients if the appropriate structures had been in place. Emergency room capacities might likewise influence the frequency of day cases: In cases of doubt, the decision whether to admit a patient depends on the outpatient physicians’ experience but also on the resources actually available to adequately determine the patient’s health status. When the emergency department is overburdened, the number of “defensive” inpa- tient admissions might rise.

The underlying reasons for the marked regional variation in day cases merit further study, as do the possibilities for mov- ing such cases into outpatient care structures.

4. Selected indicators 54

District-specific proportional quotient: (actual number of deaths in hospital / actual number of all deaths) ÷ (expected number of deaths in hospital / expected number of all deaths); deaths in hospital and all deaths among people