How often are operations unnecessary

Initiative against superfluous operations: second expert opinion via remote consultation

The number of operations in Germany is increasing. In the case of elective interventions in particular, the indications are apparently broad in some cases. Doctors are now offering second reports via an online portal. There is agreement, but there are also concerns.

When the Barmer-GEK presented its hospital report last year, even experts were surprised. Between 2003 and 2009, the rate of first hip replacements increased by nine percent, that of knee replacements by as much as 43 percent - the demographic changes

each taken into account. At the same time, the rate of revision interventions for hip replacements had increased by 41 percent and for knee replacements by 117 percent, also age-adjusted increases.

There are indications that too much surgery is being performed in Germany. This is what Prof. Dr. med. Hans-Peter Bruch, University Hospital Lübeck, President of the Professional Association of German Surgeons, and Prof. Dr. med. Hartwig Bauer, Secretary General of the German Society for Surgery. A broad indication for the operation is not necessarily for the well-being of the patient: He bears the risk of the operation, with often questionable benefits.

A group of doctors, so far mainly from the field of orthopedic surgery, would like to counteract this. Initiated by the Heidelberg surgeon Prof. Dr. med. Hans H. Pässler, the doctors set up the Internet portal “Caution Operation” (www.vorsicht-operation.de). Patients should now be able to obtain a second opinion on this. They answer questions about complaints and anamnesis online and send x-rays and magnetic resonance tomographs electronically to the reviewers. The fees are between 200 and 600 euros. Some health insurance companies are considering paying the costs.

Avoid unnecessary surgery

“The idea of ​​the portal is the right signal to increase public awareness, but also in our own profession, that we have to avoid unnecessary operations,” said Bauer in an interview with Deutsches Ärzteblatt. Hans-Peter Bruch also believes that the intention that a second medical opinion is an “important component of transparent and balanced patient information” is correct. However, it is already common practice and is paid for by the health insurance companies - with significantly lower fees.

How useful are remote advice reports? "I see the big problem with an online portal in the fact that there is no direct contact with the patient," explained Bruch. It is important for every medical consultation that the doctor himself examines that he knows the person, their wishes and the social environment and takes them into account when setting the indication. This practice is only deviated from in exceptional cases. "Especially if you have a wide margin of discretion for an indication, you should express yourself very carefully if you don't know the patient," said Bruch.

More than 13 million operations are carried out in Germany every year (Federal Statistical Office 2010). From 2005 to 2008 their number rose by around 1.5 million. The most common surgery is on the musculoskeletal system. Arthroscopic interventions are leading (approx. 600,000): on the articular cartilage, on the menisci, on the synovium and in the form of arthroscopic joint revision.

According to some doctors, the data speak against the indication for some of the therapies. A randomized study in 2002 showed that arthroscopic lavage or debridement was no more effective than sham surgery in patients with knee pain and arthrosis (NEJM 2002; 347: 81–8). A later randomized study confirmed: The effectiveness of an arthroscopic intervention combined with a conservative therapy was not higher in osteoarthritis of the knee after six and 24 months than with conservative therapy alone (NEJM 2008; 359: 1097–107). "The number of arthroscopic interventions is likely to be higher than what is medically sensible," said Bauer.

The effectiveness of vertebroplasties is also debatable. Two randomized studies published in 2009 could not find a significant effect on pain and spinal function by injecting bone cement in vertebral fractures caused by osteoporosis (NEJM 2009; 361: 557–68 and 569–79). “The European Commission asked why there are eight times as many vertebroplasties per million inhabitants in Germany as in France,” reported Bauer. “We couldn't answer the question. We lack patient data showing the findings and indications. ”The planned Care Structure Act could remedy this by making patient care data available to the relevant research institutions and specialist societies in anonymous form. Prof. Dr. med. Peer Eysel, University Clinic Cologne, in the low willingness of patients to suffer with high belief in technology and in remuneration. Eysel also only gives second opinions after personal consultation and examination. "For standardized interventions, professional societies should create guidelines on the indication," says Eysel. “For example, there are no standardized indications for spinal surgery in degenerative diseases. The same X-ray image leads to ten different pieces of advice from ten doctors. "

Economic pressure, the financing of inpatient care through flat rates per case, but also minimum quantity regulations for quality assurance could promote undesirable developments. "If a clinic wants to maintain a segment and there is still exactly one knee endoprosthesis implantation missing at the end of December, one can already imagine that in individual cases an indication is made broadly," said Bruch. But that is certainly the exception. With the portal's slogan “Caution, operation”, doctors would be placed under general suspicion: “That could arouse fundamental mistrust and disrupt the doctor-patient relationship. Most of the colleagues behave correctly. ”The State Social Court of Berlin considers the minimum quantity decision of the Federal Joint Committee for knee endoprostheses to be inadmissible. The recently passed judgment is not yet legally binding (see also page one).

Initiated meaningful debate

Georg Baum, managing director of the German Hospital Association, does not see that there is too much surgery in hospitals. Financial reasons played no role in an operation. "The decision to have an operation is made solely on the basis of the medical indication," emphasized Baum. Especially in the case of protracted illnesses such as hip or knee complaints, the decision is not made lightly.

The National Association of Statutory Health Insurance Funds welcomes the fact that, with “caution, operation” a discussion about undesirable developments has started. "The initiative shows that there is a growing awareness within the medical profession that there are always unnecessary operations," said association spokesman Florian Lanz on request. Lanz cannot imagine that the health insurances will pay for the advice on the Internet. "If we were to pay for online second opinions on a regular basis, then we would accept that the quality of medical diagnosis and advice is so poor that it becomes necessary," explained Lanz. It is important to ensure that such portals, as helpful as they may be in individual cases, are not necessary overall.

The medical lawyer Dr. jur. Albrecht Wienke from Cologne has concerns about professional law: The participation of German doctors on the portal based in Switzerland could violate the (model) professional code. There it says in Section 7 (3) that doctors are not allowed to provide individual treatment, in particular advice, neither exclusively by post, in newspapers or magazines, nor exclusively via communication media or computer networks. The North Rhine Medical Association, for example, has adopted this passage unchanged in the professional code. Since advice without patient contact is not offered as an exception, but rather systematically, it is questionable in terms of professional law, said Wienke.

Dr. rer. nat. Nicola Siegmund-Schultze

Dr. med. Birgit Hibbeler

3 questions to. . .

Prof. Dr. med. Hans H. Pässler (71), surgeon and trauma surgeon, initiator of www.vorsicht-operation.de

Primum nil nocere - do not harm the patient: have doctors forgotten this principle?

Pässler: That's right. This is not because of the doctors themselves, but because our medicine is very commercialized. One or the other indication is then made that would not be necessary. So the OP numbers get out of hand. This is a system error. Doctors are lured into it and trapped in it.

How are the reactions to your internet portal? Are there any colleagues who you see as polluting the nest?

Pässler: So far, the reactions have been positive. There were even more colleagues who would like to take part. The interest from the patient side is incredibly high. We've had days with more than 100,000 clicks.

Are you interested in a second opinion in individual cases or do you want to initiate a fundamental debate?

Pässler: A fundamental debate is certainly necessary. In the hospital we have the tiresome DRGs and volume agreements that you don't want to go below. Outpatient surgeons are also under economic pressure. For us retired experts, our online second opinion offer is also about having a nice and meaningful job.