Critical Assessment of the Current German Healthcare Quality Assurance Program Using the Example of CABG

Background: Cardiac surgeons are required to ensure and further amend the quality of the procedures they perform. Using defined quality indicators in national registries, an improvement in patient care in Germany is sought. By examination of the national registries on coronary artery bypass grafting (CABG), the current practice of quality assurance is critically studied and put into a broader perspective.

Method: Analysis of the data collection and processing of the official German quality assurance program (2011–2014: Aqua Institut and 2015–2021: Institut für Qualitätsicherung und Transparenz im Gesundheitswesen) as well as the quality indicators for CABG in the benchmark reports of the past 10 years. The results are compared with the current ESC and EACTS guidelines on myocardial revascularization.

Results: The four essential quality indicators have not been adjusted over the years and present consistent incidences (use of LIMA: 2011 91.3% vs. 2020 94.8%, sternum infection and mediastinitis: 2011 0.49% vs. 2020 0.24%, neurological complications: 2011 1.6% vs. 2020 0.68% and hospital mortality: 2011 3.0% vs. 2020 1.81%).

Surgical risk factors that significantly influence the outcome and are found in the surgical guidelines were only assessed until 2017 or have never been included (type of grafts, number of central anastomoses, completeness of revascularization, flow measurement). Many data can be obtained from diverse health system registries provided by the hospitals (rate of off-pump CABG: 15.9% (2011) vs. 22.4% (2020), length of stay: 11.4 days (2011) vs. 10.7 days (2020), mortality).

Furthermore, with the “DeQS” enactment coming into force in 2021, all procedures in patients with private health insurance (11.3%) will not be included by the quality assessment. Also, this change in quality assurance will not validate any significant points that affect the question of surgical quality.

Conclusion: To fulfill the essential task of measuring the quality, the collected data should be adjusted. Only then it is feasible to implement surgical strategies and useful measures to improve patient safety and outcome. This would also increase the compliance of the surgeons in diligent data acquisition. That more than 11% of the cases will not be included in the mandatory quality documentation of cardiac surgery must be questioned.

Publication History

Article published online:
03 February 2022