UKM Marienhospital GmbH

Quality results

Treatment sector: Pacemaker: First use (HSMDEF-HSM-IMPL) Explanation

Information about this treatment area (documentation)

Designation	Herzschrittmacher-Implantation
Shortcut	09/1
Number of cases	34
Documentation rate	100 %
Hospital comment	Die Dokumentationsrate wurde krankenhausbezogen berechnet.

Summary result:

In 9 of 10 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 34

Quality objective achieved
Quality objective not achieved

The results in detail

Show national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

This is how often the decision to insert a pacemaker for the first time was made according to the scientifically recommended guidelines

Hospital: 93,75 %

Target area: at least 90,00 %

Quality objective achieved

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The pacemaker system was selected on the basis of recognised scientific recommendations

Hospital: 100,00 %

Target area: at least 90,00 %

Quality objective achieved

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Duration of the operation (based on operations where a pacemaker was inserted for the first time or the housing of the pacemaker was replaced)

Hospital: 69,23 %

Target area: at least 60,00 %

Quality objective achieved

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Verhältnis von tatsächlicher zu erwarteter Anzahl an Patient/innen, bei denen beim erstmaligen Einsetzen eines Herzschrittmachers die wissenschaftlich empfohlene maximale Strahlenbelastung überschritten wurde

Hospital: 3,00

Target area: at most 3,11

Quality objective achieved

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Various measurements during the operation have shown that the pacemaker?s wires were functioning properly

Hospital: 96,83 %

Target area: at least 90,00 %

Quality objective achieved

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This is how rarely complications occurred during the initial insertion of a pacemaker (other than malfunction or displacement of probes: including wound infections)

Hospital: 0,00 %

Target area: at most 2,60 %

Quality objective achieved

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This ist how rarely displacements or malfunctions of probes occurred during or after insertion of the pacemaker

Hospital: Data protection

No information due to data protection

Target area: at most 3,00 %

Quality objective not achieved

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This is how often the pacemaker probes were advanced to the heart through the subclavian vein when a pacemaker was first implanted

Hospital: Data protection

No information due to data protection

as often as possible

Evaluation is not available

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Ratio of the actual number to the previously expected number of patients who died during their hospital stay (the individual risks of the patients were taken into account)

Hospital: 1,90

Target area: at most 4,38

Quality objective achieved

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Ratio of the number of problems encountered to the previously expected number (the individual risks of the patients were taken into account). The problems occurred in connection with an operation where a pacemaker was inserted (probe or pocket problems) and led to a new operation within one year

Hospital: 2,58

Target area: at most 2,69

Quality objective achieved

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Ratio of the actual number to the previously expected number of infections or complications that occurred which led to a new operation within one year (individual risks of the patients were taken into account)

Hospital: 14,01

Target area: at most 6,34

Quality objective achieved
Why?

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Code ID	101803
Result (%)	93,75
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	32
Events observed	30
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	96,25
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	96,11 - 96,39
Hospital confidence interval (%)	79,85 - 98,27
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus sets a benchmark for the assessment of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to faulty documentation, medical specificity of the patient collective or individual cases. The assessment of quality is carried out within the framework of the defined procedure in the comments procedure. Further information on reference areas can be found under the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	54140
Result (%)	100,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	32
Events observed	32
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	99,61
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	99,56 - 99,65
Hospital confidence interval (%)	89,28 - 100,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the range in which the results of an indicator are assessed as unremarkable. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialogue. It should be noted that an indicator result outside of the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also be attributed, for example, to incorrect documentation or to individual cases. The quality is assessed as part of the structured dialogue with the facilities . The choice of system for pacemaker implantations is assessed based on the current guidelines on cardiac pacemaker and cardiac resynchronization therapy from the European Society of Cardiology (Brignole et al. 2013). In individual cases there may be justified deviations from the guidelines. Brignole, M: Auricchio, A: Baron-Esquivias, G: Bordachar, P: Boriani, G: Breithardt, O-A: et al. (2013): 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal 34 (29): 2281-2329. DOI: 10.1093 / eurheartj / eht150.

Code ID	52139
Result (%)	69,23
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	39
Events observed	27
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	88,55
Target range (reference range)	>= 60,00 %
Confidence interval nationwide (%)	88,34 - 88,76
Hospital confidence interval (%)	53,58 - 81,43
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions.

Code ID	101800
Result	3,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	34
Events observed	6
Anticipated events	2,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	0,87
Target range (reference range)	<= 3,11 (95. Perzentil)
Confidence interval nationwide	0,84 - 0,90
Hospital confidence interval	1,42 - 5,70
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Risk adjustment aims to compensate for the different patient structures in different facilities. Ideally, this leads to a fair comparison of the different facilities, since patients have individual risk factors (such as concomitant diseases) that systematically influence the quality outcome, without one facility being held responsible for, for example, more frequent complications as a result. With the help of risk adjustment, the quality outcome of, for example, a facility with many high-risk cases can be statistically compared more fairly with the quality outcome of a facility with many low-risk cases. More information on risk adjustment can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen. The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus sets a benchmark for the assessment of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to faulty documentation, medical specificity of the patient collective or individual cases. The assessment of quality is carried out within the framework of the defined procedure in the comments procedure. More information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	52305
Result (%)	96,83
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	126
Events observed	122
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	95,12
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	95,03 - 95,20
Hospital confidence interval (%)	92,12 - 98,76
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the disease severity or concomitant diseases of the patients have an influence on the result. This indicator is a so-called quality index. This means that several measurements are evaluated per treatment case and that not only cases with a pacemaker implantation, but also cases with a revision, a system change or an explantation of the pacemaker are considered. The aim is to consider an increased number of measurements and thus to reduce the number of cases prevalence problem (Heller 2010). If the number of cases is low at the site level, there is a risk that computational anomalies arise randomly due to a few individual cases. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. Heller, G (2010): Quality assurance with routine data - current status and further development. Chapter 14. In: Klauber, J: Geraedts, M: Friedrich, J: Hospital Report 2010: Focus: Hospital care in crisis? Stuttgart: Schattauer, 239-254. ISBN: 978-3794527267.

Code ID	101801
Result (%)	0,00
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	34
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	0,91
Target range (reference range)	<= 2,60 %
Confidence interval nationwide (%)	0,84 - 0,98
Hospital confidence interval (%)	0,00 - 10,15
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG The reference range indicates the results at which a facility can be assumed to provide good quality of care, although deviations are possible. The reference range thus sets a benchmark for the assessment of facilities. A result outside the reference range is initially considered conspicuous. This usually entails an analysis by means of a statement procedure. It should be noted that a quality result outside the reference range is not synonymous with a lack of quality of the facility in the quality aspect considered here. The deviation can also be due, for example, to faulty documentation, medical specificity of the patient collective or individual cases. The assessment of quality is carried out within the framework of the defined procedure in the comments procedure. More information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	52311
Result (%)	Data protection
Evaluation through structured dialogue	The result is not in the target area. The hospital did not meet the quality target. There are indications of structural and process deficiencies. (A71)
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	1,28
Target range (reference range)	<= 3,00 %
Confidence interval nationwide (%)	1,20 - 1,37
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the disease severity or concomitant diseases of the patients have an influence on the result. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions.

Code ID	101802
Result (%)	Data protection
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	50,73
Target range (reference range)
Confidence interval nationwide (%)	50,37 - 51,10
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	TKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG Although indicators represent quality, their results do not allow a direct assessment of the quality of care (due to the lack of a reference range) and they are not suitable for direct quality comparisons (due to the lack of mathematical adjustment). However, they are usually published in direct connection with a quality indicator, the result of which is supplemented by the indicator values (imputed and supplementary indicators). They thus contribute to an increase in the comprehensibility of the quality results. The transparency indicators, which are to be distinguished from these, represent aspects of care for which there are no quality indicators, but which are nevertheless important for the presentation of the quality of care. More detailed information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	51191
Result	1,90
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	0,96
Target range (reference range)	<= 4,38 (95. Perzentil)
Confidence interval nationwide	0,90 - 1,01
Hospital confidence interval	0,34 - 9,62
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, as there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. The results of this quality indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule of the indicator. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/.

Code ID	2194
Result	2,58
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	0,99
Target range (reference range)	<= 2,69 (95. Perzentil)
Confidence interval nationwide	0,96 - 1,03
Hospital confidence interval	0,43 - 7,97
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, since there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. The results of this quality indicator can only be compared to the previous year's results to a limited extent due to adjustments to the calculation rule of the indicator. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/. This quality indicator shows both events that occur before discharge from a hospital and events that occur after discharge but can still be linked to the implantation.

Code ID	2195
Result	14,01
Evaluation through structured dialogue	Although the result is not in the target area, the quality target is still considered to be achieved, because the deviation can be traced back to one or more well-founded individual cases after examination by specialist committees. (U62)
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	0,99
Target range (reference range)	<= 6,34 (95. Perzentil)
Confidence interval nationwide	0,87 - 1,12
Hospital confidence interval	0,80 - 61,63
Reference infection	No
Type of value	QI
Relation to the procedure	DeQS
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG This indicator is a risk-adjusted indicator. A risk adjustment compensates for the different composition of the patient groups from different institutions. This leads to a fairer comparison, since there are patient-related risk factors (such as comorbidities) that systematically influence the indicator result without an institution being responsible for e.g. B. the following more frequent complications can be attributed. For example, the indicator result of a facility with many high-risk cases can be compared more statistically with the result of a facility with many low-risk cases. The risk factors are compiled from patient characteristics that were classified as risk-relevant as part of the development of quality indicators and which can be practically documented. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially noticeable in terms of calculation, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions. The results of this quality indicator can only be compared with the previous year's results to a limited extent due to adjustments to the calculation rule of the indicator. Further information on the adjustments made can be found in the description of the quality indicators at the following link: https://iqtig.org/qs-verfahren/. This quality indicator shows both events that occur before discharge from a hospital and events that occur after discharge but can still be linked to the implantation.