Assessment of University Gynaecology Clinics Based on Quality Reports.

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Quality reporting was initially im- plemented to offer a better means of assessing hospitals and to provide patients with informa- tion to help them when choosing their hospital. Quality reports are published every 2 years and include parameters describing the hospital ʼs structure and general infrastructure together with specific data on individual specialised de- partments or clinics.

This study investigated the 2010 quality reports of German university hospitals published online, focussing on the following data: number of inpatients treated by the hospital, focus of care provided by the unit/department, range of medi- cal services and care provided by the unit/depart- ment, non-medical services provided by the unit/ department, number of cases treated in the unit/ department, ICD diagnoses, OPS procedures, number of outpatient procedures, day surgeries as defined by Section 115b SGB V, presence of an accident insurance consultant and number of staff employed.

University gynaecology clinics (UGCs) treat 10 % (range: 6–17 %) of all inpatients of their respective university hospital. There were no im- portant differences in infrastructure between clinics. All UGCs offered full medical care and were specialist clinics for gynaecology (surgery, breast centres, genital cancer, urogynaecology, endoscopy), obstetrics (prenatal diagnostics, high-risk obstetrics); many were also specialist clinics for endocrinology and reproductive medi- cine. On average, each clinic employs 32 physi- cians (range: 16 –78). Half of them (30 –77 %) are specialists. Around 171 (117 –289) inpatients are treated on average per physician. The most com- mon ICD coded treatments were deliveries and treatment of infants. Gynaecological diagnoses are underrepresented. Zusammenfassung ! Einleitung: Die Qualitätsberichte wurden kon- zipiert, um die Kompetenz der Kliniken besser darstellen zu können, sodass Patienten sich für die Auswahl der Klinik daran orientieren können. Sie werden alle 2 Jahre veröffentlicht und enthal- ten Parameter zu den Strukturen der Kliniken, der Infrastruktur insgesamt und spezifische Daten zu den einzelnen Fachabteilungen (Disziplinen). Methode: In dieser Arbeit wurden die im Internet veröffentlichten Qualitätsberichte des Jahres 2010 der Universitätskliniken untersucht und die folgenden Daten ausgewertet: Anzahl der statio- nären Patientinnen im Gesamtklinikum, Versor- gungsschwerpunkte der Organisationseinheit/ Fachabteilung, medizinisch-pflegerische Leis- tungsangebote der Organisationseinheit/Fach- abteilung, nicht medizinische Serviceangebote der Organisationseinheit/Fachabteilung, Fallzah- len der Organisationseinheit/Fachabteilung, Diag- nosen nach ICD, Prozeduren nach OPS, ambulante Behandlungsmöglichkeiten, ambulante Operatio- nen nach § 115b SGB V, Zulassung zum Durch- gangs-Arztverfahren der Berufsgenossenschaft und personelle Ausstattung. Ergebnisse: Die Universitäts-Frauenkliniken lie- fern 10 % (von 6 bis 17 %) der stationären Fälle der jeweiligen Universitätsklinika. Bei der Be- schreibung der Infrastruktur gibt es keine rele- vanten Unterschiede. Alle UFKs decken das ge- samte Spektrum des Faches ab und sind Schwer- punkte im Bereich der Gynäkologie (operativ, Brustzentrum, Genitalkarzinome, Urogynäkolo- gie, Endoskopie), Geburtshilfe (Pränataldiagnos- tik, Risikogeburtshilfe) und die meisten auch im Bereich der Endokrinologie und Reproduktions- medizin. Im Mittel werden ca. 32 Ärztinnen und Ärzte beschäftigt (16 –78). Die Hälfte davon (30 – 77 %) sind Fachärztinnen und Fachärzte. Pro Arzt- stelle werden durchschnittlich 171 (117 –289) Patientinnen stationär behandelt. Die meisten Assessment of University Gynaecology Clinics Based on Quality Reports Die Universitäts-Frauenkliniken im Spiegel der Qualitätsberichte Authors E. F. Solomayer 1, A. Rody 2, D. Wallwiener 3, M. W. Beckmann 4 Affiliations 1 Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar 2 Gynecology und Obstetrics, University Schleswig-Holstein, Lübeck 3 Obstetrics and Gynecology, University of Tübingen, Tübingen 4 Frauenklinik, Universitätsklinikum, Erlangen Key words l" gynaecology l" obstetrics l" reproductive medicine Schlüsselwörter l" Frauenheilkunde l" Geburtshilfe l" assistierte Reproduktion received 13. 2. 2013 revised 20. 4. 2013 accepted 7. 5. 2013

DOI http://dx.doi.org/ 10.1055/s-0032-1328752 Geburtsh Frauenheilk 2013; 73: 705–712 © Georg Thieme Verlag KG Stuttgart · New York · ISSN 0016‑5751 Correspondence Prof. Erich Franz Solomayer Universitätsklinikum des Saarlandes Klinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin Kirrbergstraße 1 66424 Homburg/Saar [email protected] 705 Solomayer EF et al. Assessment of University … Geburtsh Frauenheilk 2013; 73: 705 –712 Original Article

! Quality reports are statutory reports as defined by Section 137 Book V of the SGB (Germany Social Welfare Code) which every hospital must publish every two years. Hospitals provide data based on certain pre-defined, standardised criteria. The structure of the quality reports is shown in l " Fig. 1. These publications are intended to offer patients standardised in- formation on every hospital. Quality reports are structured ac- cording to specified requirements, making it easier to compare the structures of different hospitals/clinics. Part B of the quality report aims to provide information on individual specialist clin- ics/departments. Data include the number of inpatients treated, the infrastructure of the specialist clinic, the number of diagnoses and procedures performed listed in order of frequency (10 most common), and the levels of staffing. Currently, quality reports are published every 2 years and their contents are updated. This platform aims to provide information about the respective hospital or clinic as well as more transpar- ency. One important aspect of quality reports is that all hospitals are represented within the same framework, irrespective of whether they are primary or tertiary care facilities. Hospitals of- fering the same levels of care (primary, secondary, tertiary) can be compared to one another [1 –3]. The disadvantage of the quality reports is that they focus on quantitative aspects. The reports do not reflect criteria on the quality of medical care.

and Method ! This study investigated the 2010 quality reports for university hospitals published online. The following data were assessed: " Number of inpatients treated in the university hospital (Part A) " Focus and level of care provided by the unit/department (Part B) " Medical services and care provided by the specialist depart- ment (Part B) " Non-medical services provided by the unit/department (Part B) " Number of cases treated in the unit/department (Part B) " ICD diagnoses (Part B) " OPS procedures performed (Part B) " Number of outpatient procedures (Part B) " Day surgery as defined in Section115b SGB V (Part B) " Accident insurance consultant present (Part B) " Staffing levels given as numbers of full-time employees (Part B) Summary: UGCs treat 10 % of all inpatients treated in university hospitals, making them important ports of entry for their respec- tive university hospital. Around half of the physicians are special- ists. Quality reports offer little information on the differences in competencies or medical specialties. The statutory quality re- ports are not useful for patients and referring physicians when choosing a clinic. ICD-Schlüssel sind Entbindungen und Kinder. Gynäkologische Diagnosen sind unterrepräsentiert. Zusammenfassung: Die UFKs sind mit ca. 10 % der stationären Fälle der Universitätskliniken eine wichtige Eintrittspforte für das jeweilige Uniklinikum. Beinahe die Hälfte der Ärztinnen und Ärzte sind Fachärztinnen und Fachärzte. Kompetenzunterschiede und Schwerpunkte sind aus den Qualitätsberichten nur schwer bis gar nicht abzuleiten. Die gesetzlichen Qualitätsberichte sind für Patientinnen bei der Klinikwahl und für einweisende Ärztin- nen und Ärzte bei der Beratung kaum nützlich. A B C D Data on structures and services Data on structure and services of the unit/department Quality assurance Quality management General information Organisational structure of the hospital Regional obligation to provide psychiatric care Interdisciplinary medical specialties Interdisciplinary medical services and care General non-medical services offered Research and teaching Number of hospital beds as defined in Section 108/109 SGB V Number of patients Staff Equipment General information Medical specialties Medical services and care Non-medical services Number of patients ICD diagnoses OPS procedures Outpatient procedures Day surgeries Accredited accident insurance consultant Staffing levels (physicians, nursing staff, therapists) Participation in external comparative quality assurance as defined by Section 137 para. 1 sentence 3 no. 1 SGB V (QA procedure) External quality assurance procedures mandated by federal state law in accordance with Section 112 SGB V Quality assurance for participation in Disease Manage- ment Programmes (DMP) as defined by Section 137f SGB V Participation in other procedures for external comparative quality assurance Implementation of the Agreement on Minimum Number of Cases as defined by Section 137 SGB V Implementation of resolutions taken by the Federal Joint Committee on Quality Assurance as defined by Section 137 para. 1 sentence 1 no. 2 SGB V Implementation of regulations on advanced training in hospitals as defined by Section 137 SGB V Quality policies Quality targets Establishment of quality management processes/ procedures within the facility Quality management tools Quality management projects Assessment of quality management Fig. 1 Structure of quality reports. 706 Solomayer EF et al. Assessment of University … Geburtsh Frauenheilk 2013; 73: 705 –712 GebFra Science In some cases where hospitals consisted of 2 or 3 clinics (at sev- eral speciality locations) the case numbers were simply added up. University gynaecology clinics not affiliated to university hospi- tals were not included in this study. Such hospitals have a non- university infrastructure for patient care which makes it more difficult to compare them with university facilities. The following questions were investigated: " How many inpatients were treated in the respective university hospitals? " Which quantitative differences exist between university gy- naecology clinics with regard to inpatient care? " How important is gynaecology for the inpatient care of univer- sity hospitals? " What are the quantitative differences in staffing levels be- tween university gynaecology clinics? " What information can be deduced from quality reports?

! 1. How many inpatients are treated in the respective university hospitals? Part A of the quality report listed the numbers of inpatients treat- ed in the respective hospital and clinic. The number of patients are shown in l " Table 1 . The average number of patients was 52 827 (range: 35 324 to 128 017). Six university hospitals (UHs) treated more than 60 000 patients annually (2 of which were spread over 2 and 3 locations, respectively), 10 UHs treated 50 000 to 60 000 patients, 14 UHs treated between 40 000 and 50 000, and 2 treated fewer than 40 000 patients per year. 2. Which quantitative differences exist between univer- sity gynaecology clinics with regard to inpatient care? Part B of the quality reports showed the number of inpatients in the respective gynaecology clinic. The average number of inpa- tients treated in university gynaecology clinics was 5311 (range: 2729 to 15 148). When the number of inpatients was divided ac- cording to the number of hospital sites, the average number of pa- tients treated per UGC site was 5073. Four university gynaecology clinics treated fewer than 3000 women and 5 treated more than 7000 inpatients per year. The other 23 UGCs treated between 3000 and 7000 women annually (3 UGCs treated between 3000 and 4000; 8 UGCs between 4000 and 5000; 10 UGCs between 5000 and 6000 and 2 between 6000 and 7000 women per year). 3. How important is gynaecology for the inpatient care of university hospitals? The university gynaecology clinics treated an average of 10 % of all inpatients of their respective university hospital (between 6 and 17 %). Three UGCs treated more than 13 % and 6 UGCs treated less than 8 %. 4. What are the quantitative differences in staffing levels between university gynaecology clinics? l" Table 2 shows the number of staff for the respective university gynaecology clinics. On average, UGCs employed around 32 physicians (between 16 and 78). The number of specialist physi- cians was around 16 per university gynaecology clinic (min. 8 to max. 36.5). This means that around 50 % of physicians employed were specialists (30 to 77 %). An average of 171 (117 to 289) in- patients were treated per physician. 5. What information can be deduced from quality reports? No relevant differences between UGCs were found with regard to the focus of care of the unit/department, the medical services and care offered by the unit/department, or the non-medical services provided by the unit/department. The most common diagnoses and procedures are listed in l " Ta- bles 3 and 4. The most common diagnosis was Z38 (30 clinics, range: 384 – 1559) with one clinic listing O68 as the most common (n = 399). In 3 clinics Z38 was not found among the 10 most common diag- noses. In these clinics C50 (2 clinics, 331 and 460, respectively) and O42 (1 clinic, n = 435) were the most frequently diagnosis. The second most common diagnoses were: C50 (14 clinics, range: 267–840), D25 (6 clinics, range: 144 –631), O70 (5 clinics, range: 330–445), O42 (2 clinics, range: 267 –335), O68 in two clinics (n = 428), O60 (n = 175), O34 (n = 232), N39 (n = 109) and Z38 (n = 393). Table 1 University hospitals (UH) and university gynaecological clinics (UGC) according to the number of inpatients (UGC and UH), day care patients and outpatients (UH). Sorted according to the ratio of UGC patients to UH patients given in percent. Clinic No. of in- patients per UH No. of day care patients per UH No. of out- patients per UH No. of in- patients per UGC UGC/ UH (%) 1 43 759 0 11 039 2 729 6.24 28 47 323 6 656 240 060 2 979 6.30 7 53 774 337 0 3 517 6.54 10 45 020 2 168 155 997 2 960 6.57 11 48 213 2 243 181 816 3 434 7.12 12 35 324 1 002 112 000 2 774 7.85 26 57 032 19 643 208 947 4 732 8.30 16 61 116 9 800 413 135 5 092 8.33 9 62 751 4 587 257 491 5 370 8.56 17 51 621 1 306 206 224 4 482 8.68 24 47 095 4 434 94 305 4 098 8.70 13 38 486 1 850 90 449 3 653 9.49 4 53 926 5 997 309 487 5 163 9.57 25 61 420 5 836 238 381 5 929 9.65 19 46 779 456 168 260 4 516 9.65 30 51 406 7 022 211 741 5 040 9.80 3 46 447 458 325 248 4 593 9.89 18 52 895 4 260 362 321 5 301 10.02 23 48 657 484 125 827 4 889 10.05 32 53 489 5 418 152 916 5 449 10.19 20 49 451 2 548 173 509 5 051 10.21 8 46 439 1 891 219 480 4 766 10.26 15 54 875 1 790 370 373 5 822 10.61 27 43 085 971 144 075 4 839 11.23 2 128 017 0 592 566 15 148 11.83 14 53 606 1 882 182 358 6 346 11.84 5 43 213 1 107 192 603 5 362 12.41 21 48 721 2 981 278 562 6 113 12.55 6 58 248 9 885 387 794 7 387 12.68 22 76 797 8 615 378 930 11 950 15.56 31 45 883 3 464 216 311 7 508 16.36 29 60 320 2 581 327 581 10 486 17.38 707 Solomayer EF et al. Assessment of University … Geburtsh Frauenheilk 2013; 73: 705 –712 Original Article The third most common diagnoses were obstetrical (O68, O42, O24, O34, O70, O71, O99; 24 clinics, range: 125 –344), N81 (3 clinics, range: 105 –369), C50 (3 clinics, range: 257 –311), D25 twice (n = 52 und n = 82), C56 twice (n = 97 und n = 132). The fourth most common diagnoses were mostly obstetrical (n = 14, range 116 –295), gynaecological (9 clinics, range: 70 – 275) and gynaecological oncology diagnoses (6 clinics, range: 43–347). The fifth most common diagnoses were obstetrical (n = 23, range 85–302), gynaecological (6 clinics, range: 33 –228) and gynaeco- logical oncology diagnoses (2 clinics, range: 119 –156). Thereafter, the most common diagnoses were obstetrical diag- noses (the sixth most common in 19 clinics, the seventh most common in 22 clinics, the eighth most common in 18 clinics, the ninth most common in 20 clinics and the tenth most common in 20 clinics). When assessing individual clinics according to the most common diagnoses (10 most common) of the 86 968 diagnoses made, 77.7 % (43.4–100 %) were obstetrical diagnoses. With the excep- tion of 4 clinics, the diagnosis Z38 is the most common. In one clinic it was the second most common, while in 3 clinics it did not make the top 10. 15 % of cases were gynaecological-oncology diagnoses and 7.3 % of diagnoses were purely gynaecological. The average number of gynaecological diagnoses among the top 10 was 2.5 (0 –5). The remaining 7.5 were obstetrical diagnoses. The 2010 quality reports listed 31 UHs with a level 1 perinatal centre. Only one UH did not have a level 1 perinatal centre. 17 quality reports described their facility as a CCC (comprehensive cancer centre).

! Quality reports are published every 2 years. The collected data are standardised and are intended to help patients select the op- timal clinic for their needs. The high level of standardisation has the advantage that it permits data from different clinics to be compared. But the quality reports are quite extensive and diffi- cult for patients to interpret. The contents of quality reports offer few benefits. Quality reports focus in the first instance on data re- lating to the infrastructure of the entire hospital complex (Part A of the quality report) and of the specialist clinics (Part B of the quality report), together with quantitative information such as ICD codes (diagnoses), therapies and staffing levels. However the level of specialist expertise available in the respective clinic is difficult to represent in these reports. The quality of care can- not be easily objectified. There are numerous quality criteria for every disorder, which only describe certain aspects. These quality criteria are so extensive that they cannot be integrated into a quality report. But not all diseases have quality criteria, and even when quality criteria are defined, opinions often diverge as to the significance of various criteria [4]. Quality reports are not well known. Several retrospective studies have shown that fewer than half of all surveyed physicians knew of the existence of these legally mandated quality reports. Youn- ger physicians were more likely to know about them but did not use the quality reports more frequently than their older col- leagues. Overall, only about one in ten physicians stated that they actively made use of quality reports in their original format dur- ing consultations with patients. Some preferred to use the elec- tronic versions of the quality report data, particularly in the for- mat provided by some of the numerous internet portals which offer comparisons between hospitals. Overall, the legally man- dated quality reports played only a minor role in the run-up to patients being admitted to hospital [6]. The situation is rather different for rehab clinics and psychoso- matic clinics. The quality reports of rehab clinics are consulted by (potential) users who view them as an important source of in- formation. The reports do not focus on the target group “Patients” and do not predominantly look at the most important areas of in- terest [7]. The introduction of quality reports for psychosomatic clinics provided an initial approach, allowing these clinics to be compared based on their infrastructure and the quality of their processes [8]. This study compared the quality reports of university gynaecol- ogy clinics. The question was, which data could a potential user deduce from a comparison of quality reports. When comparing university hospitals, it was noticeable that the number of inpatients per year treated at different clinics varied widely (from 35 324 to 128 017). This figure is surely of little rele- vance for patients. A university hospital with lower number of patients can possess outstanding specialist knowledge in a par- ticular field and a university hospital with high numbers of pa- tients may not offer the required expert knowledge. The proba- bility of specific specialist knowledge being available may be higher in a large university hospital compared to a small one, but the potential user has to read Part B of the quality report to Table 2 Physicians employed by UGCs. Clinic No. of in- patients per UGC No. of physi- cians No. of special- ists Special- ists/ physi- cians No. of in- patients per physician 10 2 960 16.0 8.0 50.00 185.00 1 2 729 17.3 9.3 53.76 157.75 24 4 098 18.7 9.7 51.87 219.14 17 4 482 19.8 7.6 38.38 226.36 11 3 434 20.5 9.7 47.32 167.51 12 2 774 21.8 16.8 77.06 127.25 13 3 653 22.9 7.7 33.62 159.52 4 5 163 24.6 11.6 47.15 209.88 15 5 822 25.0 13.0 52.00 232.88 28 2 979 25.5 17.0 66.67 116.82 26 4 732 25.9 10.8 41.70 182.70 31 7 508 26.0 14.0 53.85 288.77 8 4 766 26.5 14.0 52.83 179.85 21 6 113 27.0 17.0 62.96 226.41 7 3 517 27.0 18.0 66.67 130.26 9 5 370 30.4 16.9 55.59 176.64 25 5 929 30.5 18.5 60.66 194.39 32 5 449 31.8 13.0 40.94 171.62 3 4 593 31.8 9.7 30.50 144.43 20 5 051 32.0 20.0 62.50 157.84 5 5 362 32.6 14.9 45.71 164.48 18 5 301 32.8 14.0 42.68 161.62 27 4 839 34.3 13.3 38.78 141.08 23 4 889 36.7 17.2 46.87 133.22 14 6 346 36.7 17.9 48.77 172.92 19 4 516 37.7 21.0 55.70 119.79 16 5 092 37.8 15.3 40.48 134.71 6 7 387 41.5 13.5 32.53 178.00 30 5 040 41.8 21.7 51.91 120.57 29 10 486 50.8 31.5 62.01 206.42 22 11 950 73.5 36.9 50.20 162.59 2 15 148 78.0 36.7 47.05 194.21 708 Solomayer EF et al. Assessment of University … Geburtsh Frauenheilk 2013; 73: 705 –712 GebFra Science Table 3 The 10 most common diagnoses in each UGC. K l . D 1N 1 D 2N 2 D 3N 3 D 4N 4 D 5N 5 D 6N 6 D 7N 7 D 8N 8 D 9N 9 D 1 0 N 1 0 12 C50 331 D25 144 O99 125 O24 116 O70 115 O60 115 C56 79 C54 71 D27 69 O42 62 18 O42 435 O68 428 O24 344 O69 254 O36 252 O48 252 O64 199 O34 199 O26 183 O99 157 4 O68 399 Z38 393 O42 391 C50 347 O60 302 O34 214 Q66 198 O48 153 O64 146 P08 136 1 Z38 492 O60 175 O34 171 O36 117 O42 99 C50 94 D25 82 O48 68 O99 65 N83 47 2 Z38 742 O42 267 O34 145 O48 125 O99 85 O68 78 O70 72 O75 72 O28 66 O36 62 3 Z38 927 C50 245 O70 219 O36 188 O34 178 O42 171 O35 162 O60 147 C56 125 Q65 123 5 Z38 1 319 O70 330 O34 255 C50 229 O68 170 O42 160 O63 160 O80 151 O64 131 D25 128 6 Z38 1 177 C50 840 O70 279 D25 275 O68 270 O42 254 N80 241 C56 229 D24 179 O34 131 7 Z38 617 C50 305 O70 165 D25 140 C56 119 O68 108 O34 104 O60 101 O65 89 O26 86 8 Z38 922 C50 339 O68 248 O70 223 O60 217 O42 196 O71 141 P07 124 P08 109 O34 102 9 Z38 548 C50 314 O34 283 O68 207 O70 196 O24 191 O99 154 O60 137 D25 106 O42 87 10 Z38 667 O34 232 O42 166 D25 144 O36 95 O68 92 O75 84 O70 78 C50 71 O99 71 11 Z38 459 C50 400 O34 194 C53 143 O42 141 C56 128 O99 121 C54 77 O36 71 O71 70 13 Z38 622 C50 267 O42 250 O36 146 P08 126 D25 110 O26 104 O68 93 O48 92 O34 91 14 Z38 1 263 O70 406 P08 318 C50 303 O68 284 O32 252 O42 233 O63 218 O34 198 O80 146 15 Z38 879 D25 326 C50 277 O42 270 O34 230 O69 189 O70 188 O36 134 O26 125 O99 107 16 Z38 689 C50 660 O70 310 O34 266 O60 191 O68 171 P07 127 N81 112 D25 111 C56 83 17 Z38 897 C50 269 O70 215 O80 179 D25 159 O60 122 O65 111 O36 106 N83 97 O42 81 19 Z38 671 C50 636 O70 291 O71 255 D25 223 O34 140 O42 100 D05 96 O62 94 N83 79 20 Z38 746 C50 557 O34 241 O60 234 O36 199 O70 171 P07 145 D25 134 O99 94 P22 90 21 Z38 1 559 O70 392 O71 252 O60 242 O68 224 C53 161 O64 146 O34 144 C50 141 O42 122 22 Z38 491 O70 359 C50 257 O34 242 O71 155 D25 144 O42 136 C56 114 O32 110 P07 103 23 Z38 582 C50 373 O70 221 P08 194 O34 174 N80 160 D25 153 O60 141 O71 128 O68 124 24 Z38 622 C50 267 O42 250 O36 146 P08 126 D25 110 O26 104 O68 93 O48 92 O34 91 25 Z38 1 057 O42 335 C50 311 O68 174 C53 156 D25 149 N39 145 O34 134 O60 134 N81 126 26 Z38 384 C50 286 O68 280 O60 173 O34 159 O99 151 P08 144 P21 139 O42 129 D25 124 27 Z38 857 C50 468 O70 232 O68 178 O34 174 O80 157 D25 145 O60 115 O63 108 C56 97 28 Z38 534 C50 252 O42 159 N80 110 O34 108 O70 93 O99 73 D05 66 O36 66 D25 64 29 Z38 1 755 C50 677 D25 631 N81 369 O42 324 O70 263 N83 258 O34 230 O60 229 N39 228 30 Z38 970 O70 445 O71 310 C50 303 Z03 226 O34 141 O42 133 O68 115 O64 98 O99 95 31 Z38 1 417 C50 449 O70 366 O68 339 O42 305 O34 253 P05 189 N81 171 O24 159 P07 148 32 Z38 1 090 C50 464 O70 359 O71 278 O82 239 C56 229 O42 128 D25 118 O34 95 O02 92 C50 Malignant neoplasm of breast C53 Malignant neoplasm of cervix uteri C54 Malignant neoplasm of corpus uteri C56 Malignant neoplasm of ovary D05 Carcinoma in situ of breast D25 Leiomyoma of uterus D27 Benign neoplasm of ovary N39 Other diseases of urinary system N80 Endometriosis N81 Female genital prolapse N83 Non-inflammatory disorders of ovary, fallopian tube and broad ligament O24 Diabetes mellitus in pregnancy O26 Maternal care for other conditions predominantly related to pregnancy O32 Maternal care for known or suspected malpresentation of foetus O34 Maternal care for known or suspected abnormality of pelvic organs O42 Premature rupture of membranes O48 Prolonged pregnancy O60 Preterm delivery O63 Long labour O64 Obstructed labour due to malposition and malpresentation of foetus O68 Labour and delivery complicated by foetal distress O70 Perineal laceration during delivery O71 Other obstetric trauma O75 Other complications of labour and delivery, not elsewhere classified O80 Single spontaneous delivery O81 Single delivery by forceps and vacuum extractor O82 Single delivery by caesarean section O99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium P05 Slow foetal growth and foetal malnutrition P07 Disorders related to short gestation and low birth weight, not elsewhere classified P08 Disorders related to long gestation and high birth weight Q65 Congenital deformities of hip Q66 Congenital deformities of feet P21 Birth asphyxia P22 Respiratory distress of newborn P24 Neonatal aspiration syndromes Z03 Medical observation and evaluation for suspected diseases and conditions Z13 Special screening examination for other diseases and disorders Z38 Mature liveborn infant 709 Solomayer EF et al. Assessment of University … Geburtsh Frauenheilk 2013; 73: 705 –712 Original Article Table 4 The 10 most common 10 OPS codes used in each UGC. Clinic OPS1 N1 OPS2 N2 OPS3 N3 OPS4 N4 OPS5 N5 3 1-208 825 5-749 803 5-758 505 9-261 208 5-870 158 14 8-542 3 041 9-262 1 892 5-758 1 104 9-261 861 5-749 787 16 8-542 3 901 8-547 2 727 6-001 1 456 6-002 1 178 9-262 1 064 12 9-260 327 5-758 272 5-749 253 5-870 191 5-738 180 4 9-260 1 057 9-262 1 056 1-208 997 5-758 766 5-749 563 32 9-261 454 8-542 384 5-740 424 5-758 323 5-401 285 18 9-261 1 180 9-262 1 173 8-542 970 5-758 859 8-547 437 26 9-261 1 328 9-262 1 107 8-543 965 1-208 896 5-758 721 13 9-262 884 1-208 854 5-749 434 1-671 423 5-704 414 27 9-262 1 099 5-401 526 5-740 448 5-870 396 5-758 374 2 9-262 3 301 9-261 2 726 1-208 2 425 9-260 1 887 8-910 1 761 1 9-262 876 5-749 239 9-260 183 5-740 162 9-261 156 5 9-262 1 679 5-740 628 9-260 511 5-758 465 5-740 424 6 9-262 1 688 1-208 1 562 5-758 846 8-542 846 9-261 697 7 9-262 657 1-242 623 5-749 476 9-260 317 5-870 284 8 9-262 1 473 5-758 976 5-749 631 9-261 527 5-870 235 9 9-262 1 344 8-930 1 237 1-208 943 5-741 711 3-05 d 596 10 9-262 1 445 5-740 458 9-261 437 5-730 381 5-758 283 11 9-262 552 5-741 336 9-261 332 9-401 295 5-401 250 24 9-262 1 157 9-260 515 5-738 357 9-261 308 5-730 276 15 9-262 1 718 9-261 599 5-749 561 5-758 468 9-260 414 19 9-262 1 303 5-758 662 9-260 634 1-208 572 5-740 458 20 9-262 1 450 5-749 815 8-711 511 9-260 446 5-870 423 21 9-262 1 565 5-758 908 9-261 822 5-730 705 9-260 615 22 9-262 3 398 1-208 2 950 9-261 2 623 5-758 2 406 8-910 2 198 23 9-262 999 5-758 508 9-401 473 5-740 428 1-208 364 31 9-262 2 541 1-208 1 797 5-758 1 593 9-261 1 404 5-730 823 25 9-262 1 375 9-261 830 8-910 769 5-740 534 5-738 414 17 9-262 1 011 1-208 943 5-749 417 5-758 345 5-738 255 28 9-262 682 5-749 411 5-401 291 5-758 259 9-401 244 30 9-262 1 296 5-758 981 8-910 866 8-930 777 5-749 631 29 9-262 2 677 5-983 1 295 9-260 1 197 5-758 1 118 5-740 1 020 Clinic OPS6 N6 OPS7 N7 OPS8 N8 OPS9 N9 OPS10 N10 13 9-261 403 5-758 299 5-932 254 5-401 240 5-870 229 32 5-870 230 5-756 220 5-683 205 5-690 177 5-653 162 3 5-754 146 1-672 142 9-262 130 9-260 98 5-543 97 29 8-910 792 5-704 786 5-657 772 1-853 771 5-681 709 14 5-892 745 8-547 442 9-260 438 8-547 442 5-870 296 16 8-543 877 5-749 845 8-930 678 5-758 495 8-800 417 18 5-401 285 5-704 268 5-749 268 5-549 267 6-001 226 12 5-683 177 9-261 160 8-522 150 3-990 141 9-401 140 27 5-683 248 9-401 231 5-657 229 9-261 196 9-260 176 4 5-738 470 8-910 382 9-261 381 8-542 340 5-730 238 2 5-749 1 602 5-758 1 000 5-730 634 1-472 614 5-738 536 26 5-749 506 6-001 490 8-910 209 8-547 208 5-740 195 1 5-758 124 5-738 117 5-683 97 5-690 88 5-651 67 5 9-261 402 5-738 241 5-690 158 5-728 139 5-870 135 6 5-749 695 8-910 658 5-730 641 5-401 572 5-657 568 7 5-758 267 5-730 256 5-657 255 8-910 220 9-261 217 8 5-720 201 5-401 181 5-756 136 1-672 128 5-690 107 9 5-758 494 5-881 448 9-261 391 9-260 328 5-870 327 10 1-208 256 5-983 236 5-738 210 9-280 198 5-683 184 11 5-870 238 5-758 194 5-738 186 8-543 185 5-886 162 24 5-758 271 5-749 243 8-910 219 5-683 184 8-542 173 15 5-738 381 5-681 327 5-469 221 5-683 202 5-651 187 19 5-870 384 3-760 318 5-401 295 5-657 272 5-681 230 20 5-886 410 5-758 324 5-401 317 9-261 230 5-681 158 21 5-749 587 8-020 502 8-910 428 5-738 389 3-990 308 22 5-749 1 162 8-132 1 033 8-930 672 9-260 439 5-690 398 23 5-738 260 5-401 241 9-260 231 3-760 217 5-683 215 31 5-749 625 5-740 582 5-401 378 8-930 376 8-980 370 25 5-704 386 9-260 286 5-683 237 1-471 221 5-749 200 17 5-740 253 5-651 241 5-469 236 5-870 214 5-401 186 28 9-260 238 9-261 234 5-870 176 5-702 170 1-900 144 30 8-810 283 5-401 270 5-870 246 5-657 202 5-886 172 710 Solomayer EF et al. Assessment of University … Geburtsh Frauenheilk 2013; 73: 705 –712 GebFra Science find out. To usefully compare the number of inpatients per year, it is necessary to look at and compare numerous quality reports. Very few users are likely to make the effort [9]. The same applies to comparisons of university gynaecology clin- ics. The number of inpatients ranges from 2729 to 15 148 inpa- tients/year. One significant factor for this wide range could be the amalgamation of several different sites to form a single uni- versity hospital (e.g. Berlin, Munich). But once this point was fac- tored in (recalculated into number of inpatients/site), there are still big differences in the number of patients treated per univer- sity gynaecology clinic (range: 2729 to 10 486 inpatients/year). Thus, there was a correlation between patient numbers of UGCs and those of the UHs. This correlation is unsurprising and can best be explained by the local conditions (site, radius, competi- tors). 60 % of UGCs treated between 4000 and 6000 patients, and 77 % treated between 3000 and 7000 inpatients per year. The lo- cal healthcare infrastructure for the area where the respective university hospital was sited played a decisive role. For some uni- versity hospitals, local circumstances dictated that they were also needed to provide primary and secondary care, while in other re- gions the UHs existed alongside numerous competitors. In terms of percentages, the UGCs with their 10 % of inpatients are an important part of their UH. 77 % of UGCs treat between 7 and 12 % of patients; 17 % of UGCs even treat more than 12 % of their university hospital ʼs annual inpatients. UGCs therefore rep- resent an important port of entry for other specialist clinics. These include, in the first instance, the neonatology departments, which receive most of their cases directly from the UGC. Oncol- ogy patients from a UGC are very important for every UH because of the interdisciplinary cooperation required to treat these pa- tients. These patients receive treatment from other departments such as Radiodiagnostics, Nuclear Medicine, Radiotherapy, Inter- nal Medicine, Abdominal Surgery, Urology, Neurology, Neurosur- gery, Orthopaedics, etc. Thus, every UGC is a key department for its respective UH and represents an important economic factor. There were also important differences in staffing levels between UGCs. With numbers of resident physicians ranging from 16 to 78, the differences are significant. The numbers of patients treat- ed per full-time physician also differed greatly. These differences were due to differences in teaching and research facilities, the calculation of inpatient numbers (all children or only some of them or none credited to the inpatient numbers of the UGC), out- patient care, accreditation with statutory health insurance com- panies, etc. But this data does not make it possible to describe one clinic as “more effective” than another. In addition, research and teaching are part of the services pro- vided by a UGC but they are not taken into consideration in the quality reports. Cross financing of staff using the budget for re- search and teaching is often necessary to guarantee patient care. In many cases, when staffing levels are calculated, the calculation does not include outpatient services (outpatient consultations, etc.). Outpatient services are only profitable if they can be used to recruit inpatients or patients for day surgery procedures. Con- trols or follow-up visits are not taken into account. The number of medical specialists could be another possible indi- cator when assessing a UGC. However, here again comparisons are tricky as medical specialists may work in different capacities (e.g. senior physician). The quality report does not show the level of qualifications obtained, the experience, medical speciality, etc. of individual physicians. This means that the quality reports offer no accurate chance of comparing clinics on the basis of staffing ratios. Patients are not provided with this background information and they may even draw the wrong conclusions. The range of services provided by UGCs varies greatly. It is virtu- ally impossible to deduce which areas a hospital has specialised in based on the data obtained from quality reports. The data are based on ICD codes (diagnosis). These codes do not reflect quality of treatment or medical expertise. The most common diagnoses (ICD codes) are obstetrical and in- clude deliveries, care of neonates and suturing after vaginal de- livery. This provides an approximate figure which allows the number of deliveries to be estimated. The rate of transfers of neo- nates to the neonatology department is inconsistent. For 3 clin- ics, Z38 was not among the top 10 diagnoses. In these cases, all newborns were probably assigned to the paediatric clinic and not to the gynaecological clinic. The number of gynaecological di- agnoses and surgical procedures was therefore often lower than for obstetrics. The level of gynaecological expertise is difficult to Table 4 The 10 most common 10 OPS codes used in each UGC. (continued) 1-208 Recording of evoked potentials 1-242 Audiometry, paediatric audiometry 1-661 Diagnostic urethrocystoscopy 1-671 Diagnostic colposcopy 1-672 Diagnostic hysteroscopy 1-853 Diagnostic (percutaneous) puncture and aspiration of the abdominal cavity 5-892 Other incisions of the skin and hypodermis 3-05 d Endosonography of female genitalia 3-760 Probe measurement in SLNE (sentinel lymph node extirpation) 5-401 Excision of individual lymph nodes and lymphatic vessels 5-469 Other intestinal surgery 5-543 Excision and destruction of peritoneal tissue 5-549 Other abdominal surgery 5-569 Other ureteral surgery 5-657 Adhesiolysis of ovary and fallopian tube without microsurgery 5-683 Exstirpation of the uterus (hysterectomy) 5-704 Vaginal colporrhaphy and pelvic floor plasty 5-730 Artificial rupture of membranes (amniotomy) 5-738 Episiotomy and suturing 5-740 Classic caesarean section 5-741 Caesarean section, supracervical and corporal 5-749 Other caesarean section 5-756 Removal of retained placenta (postpartum) 5-758 Reconstruction of female genitalia after rupture, postpartum (perineal tear) 5-870 Partial (breast-conserving) excision of the breast and destruction of breast tissue without axillary lymphadenectomy 5-983 Re-operation: this additional code must be used if the operated area is re-opened to treat a complication, to perform an operation for recurrence 5-932 Type of material used for tissue replacement and tissue reinforcement 6-001 Administration of drugs, list 1 6-002 Administration of drugs, list 2 8-132 Bladder manipulations 8-542 Uncomplicated chemotherapy: 1 day 8-543 Moderately complex and intensive chemotherapy administered over more than 1 day 8-547 Other immunotherapy 8-711 Mechanical ventilation and assisted ventilation of neonates and infants 8-910 Epidural injection and infusion for pain therapy 8-930 Monitoring of breathing and cardiovascular parameters without measurement of pulmonary artery pressure or central venous pressure 8-980 Intensive medical care for complex treatment (basic procedures) 9-260 Monitoring and delivery for a normal birth 9-261 Monitoring and delivery for a high-risk birth 9-262 Postpartum care of the neonate 9-401 Psychosocial interventions 711 Solomayer EF et al. Assessment of University … Geburtsh Frauenheilk 2013; 73: 705 –712 Original Article deduce based on the services provided. From the point of view of an external observer, it is very difficult to infer the level of exper- tise present in a specific clinic based on the list of ICD and OPS codes. There are no figures on complications, morbidities or even survival rates. All of the UGCs are virtually identical with regard to equipment, facilities and medical specialties. All UGCs have breast centres, gynaecological oncology centres, pelvic floor centres, perinatal centres, centres for minimally invasive surgery, prenatal diagnos- tics and urodynamics. It is not possible to obtain information use- ful for patients based on the list of the UGC ʼs medical specialties given in the quality report. Moreover all UGCs have virtually the same facilities and equipment. All UHs are now level I perinatal centres. At the time of publica- tion, only one UH was not a level I perinatal centre but it became one shortly thereafter. 17 UHs described themselves as a CCC. However not all CCCs are supported by German Cancer Aid. The term CCC is not protected, making it impossible for readers to dif- ferentiate between centres. UGCs have not been previously compared. In a study on obstet- rics by Bauer et al. [5] published in 2011, home births were com- pared with delivery in hospital. The intact perineum rate was higher for home births, but there were no differences with regard to Apgar 10 scores. But pre-selection of cases in this study cannot be excluded. Hospital births will obviously include higher rates of high risk births. The choice of a home birth is generally done after considering the risk factors. We found no other comparisons us- ing the quality reports. Overall, it is very difficult for patients and for the physicians who arrange their admission to hospital to obtain crucial information from quality reports. Quality reports contain too much information. Around one third of all published data are superfluous [10]. Disadvantages of qual- ity reports include a lack of indicators providing information on patientsʼ experiences and the clinic ʼs reputation. A survey of po- tential user groups would provide better descriptions [10]. Pa- tients prefer quality comparison graphs which provide a lot of in- formation and rank hospitals [10]. The text sections in the re- ports aimed at patients are currently not easy to read and are not formulated so that they can be easily understood [12]. Legally mandated quality reports are currently not used by physicians as a useful source of information when advising pa- tients. For this, quality reports would have to become more widely known and physicians would have to place more confi- dence in this form of reporting. Some of the objective data on structures and services required by physicians is already in- cluded in the quality reports. But it would be important to con- sider how “soft” factors could additionally be included in these reporting tools [11]. The readability and comprehensibility of texts for patients could still be improved. It has been suggested that patients and physicians working outside hospitals could of- fer concrete approaches and proposals on changes to be imple- mented when drawing up quality reports in future [7, 12]. In 2007 Streuf et al. [13] investigated the most important criteria behind patient selection of a particular hospital. It turned out that the advice most relied on and accorded the greatest impor- tance was the information given to a patient by his or her family doctor. Newspapers, journals and the internet came second. However, in the ranking of importance, the internet ranked be- low the advice given by the family physician and information ob- tained from friends and relatives. The most important selection criteria were a hospitalʼs good reputation, a good cooperation be- tween the hospital and physicians working outside the hospital, and the number of cases treated. Of these criteria, only the num- ber of cases treated can be obtained from quality reports. Five years ago, quality reports played almost no role in hospital selec- tion by patients. It should be noted that quality reports have changed very little in recent years and it must be assumed that the criteria referred to above are still applicable today. In summary, quality reports use a very broad brush to describe the infrastructure and services of the UHs. The specific character- istics of a UGC within a hospital offering comprehensive inpatient and outpatient care and special consultation services which are time-consuming, demanding and require high staffing levels are not reflected in the quality report. The quality of treatment is not shown. For external readers it is extremely difficult to find any differences between UGCs. UGCs are an important part of UHs. Conflict of Interest ! None.

1 Lux MP, Reichelt C, Karnon J et al. Kosten-Nutzwert-Analyse endokriner Therapien in der adjuvanten Situation der postmenopausalen Patien- tin mit einem hormonrezeptorpositiven Mammakarzinom auf Basis der Überlebensdaten und Berücksichtigung zukünftiger generischer Preise aus der Sicht des deutschen Gesundheitswesens. Geburtsh Frau- enheilk 2011; 71 – P210 2 Simoes E, Brucker S, Beckmann MW et al. Screening for cervical cancer – minimise risks – maximise benefits. Need for adaptation in Germany in light of the European guidelines and their objectives. Geburtsh Frauenheilk 2013; 73: 623 –639 3 Diedrich K, Strowitzki T, Kentenich H. The state of reproductive medi- cine in Germany. Geburtsh Frauenheilk 2012; 72: 225 –234 4 Schmidt M, Fasching PA, Beckmann MW et al. Biomarkers in breast can- cer – an update. Geburtsh Frauenheilk 2012; 72: 819 –832 5 Bauer SH, Wiemer A, Misselwitz B et al. Ergebnisse des Pilotprojekts zum Vergleich klinischer Geburten (Hessen) mit außerklinischen Ge- burten (Bund). Z Geburtshilfe Neonatol 2011; 215 – FV01_01; DOI: 10.1055/s-0031-1293211 6 Hermeling P, Geraedts M. Kennen und nutzen Ärzte den strukturierten Qualitätsbericht? Gesundheitswesen 2012; DOI: 10.1055/s-0032- 1321744 7 Seidel G, Haase I, Walle E et al. Verständlichkeit und Nutzen von Quali- tätsberichten Rehabilitation aus Sicht der Nutzer. Gesundheitswesen 2009; 71 – A254; DOI: 10.1055/s-0029-1239304 8 Jagdfeld FH. Struktur-, Prozess- und Ergebnisqualität psychosomati- scher Kliniken im strukturierten Qualitätsbericht nach § 137 SGB V. Psychother Psych Med 2008; 58 – S78; DOI: 10.1055/s-2008-1061584 9 Lux MP, Hildebrandt T, Bani M et al. Health economic evaluation of dif- ferent decision aids for the individualised treatment of patients with breast cancer. Geburtsh Frauenheilk 2013; 73: 599 –610 10 Schwartze D, Geraedts M. Eignung von Qualitätsindikatoren und gra- fischen Qualitätsvergleichen zur informierten Krankenhauswahl durch Patienten. Gesundheitswesen 2006; 68 – A114; DOI: 10.1055/s- 2006-948670 11 Hermeling P, de Cruppé W, Geraedts M. Qualitätsberichte zur Unterstüt- zung der ärztlichen Patientenberatung. Gesundheitswesen 2011; 73 – A90; DOI: 10.1055/s-0031-1283480 12 Friedemann J, Schubert H-J, Schwappach D. Zur Verständlichkeit der Qualitätsberichte deutscher Krankenhäuser: Systematische Auswer- tung und Handlungsbedarf. Gesundheitswesen 2009; 71: 3 –9 13 Streuf R, Maciejek S, Kleinfeld A et al. Informationsbedarf und Informa- tionsquelle bei der Wahl eines Krankenhauses. Gesund Ökon Qual Manag 2007; 12: 113 –120 Deutschsprachige Zusatzinformationen online abrufbar unter: www.thieme-connect.de/ejournals/toc/gebfra. 712 Solomayer EF et al. Assessment of University … Geburtsh Frauenheilk 2013; 73: 705 –712 GebFra Science