The therapy of oropharyngeal carcinoma includes resection of the primary tumor with neck dissection and reconstruction. Chemotherapy or radiotherapy might be necessary for advanced stages [13]. MDT approaches for head-neck tumors have been shown in various retrospective and prospective studies to refine disease staging, treatment plans and to increase survival rates [14,15,16,17,18,19]. Also, they could enable faster treatment and shorter time of hospitalization [20,21,22]. Wheeles et al. could prove in a setting of patients with head-neck tumors, that approximately 27 % of the patients revealed changes in tumor diagnosis, stage, or treatment plans after undergoing an MDT discussion. Other studies confirmed these results [23, 24]. Loevner et al. discovered changes in image interpretation in 41 % of patients after MDT reevaluation [25].
Following its certification in the year 2013 as an interdisciplinary centrum for head-neck tumors, the university hospital Aachen revealed a significant increase in cases. Those results are not surprising considering that patients are aiming especially for certified centers hoping to receive the highest standard of quality in terms of medical performance but also other factors like psychological assistance or case management. Additionally, every certification may lead to an increase in popularity and advertisement.
In this study we tried to evaluate, whether the overall case complexity has changed since certification, assuming that more severe cases are treated in certified centers to guarantee the absolute best outcome. The PCCL value, which summarizes the secondary diseases, and CMI, as overall average case severity, is most likely reflecting the complexity [26]. Although these values may indicate the case complexity, a full medical comparison would still have to include TNM classification, former surgeries, and radiotherapy, which do not directly influence the CMI but increase surgery duration. Nevertheless, the CMI encountered a significant increase, which is accompanied by the hours of surgery and hours of ventilation, which reflects a higher surgical effort and case complexity.
On contrary, the PCCL decreased significantly, which however must be regarded cautiously because it has faced several modifications throughout the study. Values above 4 in 2016 and 2017 were consequently downsized to 4. All this led to a general flattening of the PCCL incline curve. Additionally, patients rested significantly less time under intensive care surveillance. Accordingly, the overall days of stay in the hospital decreased significantly. This shortness in stay duration can be explained by an increasing cost pressure for hospitals nowadays, a higher level of specialization, professionalism, and discharge management, a higher frequency of similar case encounters, but also a higher case number, which allows a more sophisticated postoperative handling [27, 28]. The better case planning in terms of a preoperative diagnostic and staging phase, but also a prompt application for rehabilitation are all quality features, which are implemented in the certification. Kelly et al. could prove accordingly, that patients undergoing MDT could be discharged more than a week earlier, suspecting a decrease in the overall waiting time as the cause [20].
Another important aspect of this study was to evaluate possible financial changes following certification. The average deficit between costs and reimbursement per case increased after 2012 without reaching significance (308€ vs. 854€, p = 0.7616). The DRG reimbursement is calculated by multiplying CMI and the state-wide base rate (“Landesbasisfallwert”), which is negotiated retrospectively every year and increased continuously over the years. Since the relation between reimbursement and the state-wide base rate is reflected by the CMI, we reason, that the increased reimbursement costs can be explained by an increasing CMI [29, 30]. Due to the retrospective character of this study, an actual cost determination of each patient case at the university hospital Aachen was not possible and we had to refer to average DRG costs derived from the German association of university hospitals. Since the database of reference clinics was not published by the association, cost analysis should be regarded cautiously. Nevertheless, the method of surgical intervention did not change relevantly over time and therefore did not impact cost development. So far our study group comprehends additional charges only for few occasions: Patient-specific implants (plates), which were not part of this collective, and prolonged intensive care unit stays. Our analysis did not include those center surcharges and further compensations.
Derived from our data and other studies, we could observe that it was difficult for hospitals to cover all expenses only by DRG reimbursement in this group of patients over the years [31]. Although the general stay duration decreased, costs climbed significantly, because the last days of stay are in general linked to the lowest costs. Also, regarding the DRG-reimbursement curve, compensation costs are equal between the minimal and maximal marginal stay duration, which therefore hardly enables a cost reduction. On the other hand, the general cost increase can be well explained by the higher degree of patient complexity and longer operation time. A huge disadvantage of the DRG compensation is its retrospective approach, which adapts the reimbursement height annually to the costs of the previous years [27, 32]. The broader implementation of additional charges (“Zusatzentgelte”) or new examination and treatment methods (NUB) for covering expensive procedures and products could facilitate the reimbursement of high-priced medicine and foster innovations, although there is little evidence so far [33, 34]. Performance-based remuneration could additionally motivate to improve the efforts undertaken. This could include e.g., overall survival rate, degree of relapse, hospital stay length, or changes in life quality indexes postoperatively, but should always be related to the PCCL, CMI, and further aspects as former surgeries or tumor stage. Lerch et al. proposed alternatively to separate the DRG System between a University Hospital U-DRG-System and a general G-DRG-System, thereby creating an independent system for more complex and costlier cases [31]. Additionally, the process of certification should not be underestimated in terms of its accompanying establishment fees. To enable and maintain such quality, recertification, and a lot of personal and financial resources (case management, psych oncological care, interdisciplinary tumor conferences) are required. Kelly et al. described, that any additional administrative costs could be compensated by the savings, which can be achieved by a better patient evaluation [20]. Some studies are doubting the potential benefits of MDT, declaring them as too costly and inefficiently, assuming that MDT should be rather be reserved for complex cases [35,36,37]. Other studies could, on contrary, prove that during MDT meetings most of the time was spent on complex and advanced cases, while simple cases were finished off quickly [38, 39]. However, cost analysis evaluation stays until today scarcely investigated [40].