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.

Aim of the study: To calculate minimum-provider-volumes in total knee replacement by means of German routine data for the first time.

Materials and methods: In patients with primary total knee replacement (TKR) the correlation between hospital volume per year and risk of “insufficient mobility” (primary quality indicator) and “wound infection” (secondary quality indicator) was calculated by means of logistic regression models based on the data of 110.349 primary total knee replacements operated in 1.016 German hospitals in 2004.

Results: For both indicators a statistically significant relationship between hospital volume and outcome could be proven. Other risk factors such as age and ASA-status also had a significant influence, but did not appear as important confounders. The risk for the secondary quality indicator “infection” decreased constantly by increasing hospital volume, thus the curve was very flat. This supports the hypothesis that high volume hospitals show up to have a higher quality level than low-volume hospitals. A threshold value of 116 TKR per year (95% CI 90–141) could be calculated. However, the explanation value of the hospital volume was too low to derive a threshold level that clearly discriminates between good and bad quality of care. The relationship between the primary quality indicator “insufficient mobility” and the hospital volume unexpectedly showed a U-shaped distribution. This questions the concept of a minimum provider volume regulation for primary total knee replacement regarding the risk factor “insufficient mobility”. Therefore, in this case no quantitative threshold values were calculated.

Conclusion: This analysis supports the hypothesis of a volume-outcome-relationship in primary total knee replacement. However, a minimum provider volume that clearly discriminates between good and bad quality of care could not be calculated on basis of German quality assurance data.

Aims: Aim of this study was to evaluate the clinical and radiological results after operative treatment of congenital clubfoot by the Cincinnati-approach

Methods: Between 1996– 2000 52 children with congenital clubfoot were operated with a peritalar release by using the Cincinnatti approach. 35 of them were male, 17 female. 24 had clubfeet on both sides. The age at operation was 3–17 months (mean 5,3 months). The age at follow up was 24–90 months (mean 58 months). In the follow-up at least 2 years after operative treatment the results were analysed by the score of McKay. In addition we evaluated the radiographs by the standard method of Simons.

Results: In the postoperative clinical evaluation using the McKay-Score: we found in 35% excellent, 41% good, 21% fair, 2% poor, 1% bad results. The Simons-Score was used to evaluate the radiographic postoperative results. The talocalcaneal angle a.p. was in 19% < 20° (= incomplete correction), in 76% between 20° and 40° (= normal) and in 5% > 40° (= overcorrection). The talo-calcaneal angle lateral was in 8% < 30° (= incomplete correction), in 82% between 30° and 50° (= normal) and in 10% > 50° (= overcorrection). The position of the navicular bone in the apview was in 65% 0 (= normal), in 20% +1/+2 (= overcorrected but satisfactory), in 3% +3/+4 (= marked overcorrection, not satisfactory) and in 12% (−) (= incomplete correction).

Conclusion: In conclusion by using this protocol we could show a high frequency of satisfactory results concerning function and cosmetics.