Herz- und Gefäßzentrum Bad Bevensen

Quality results

Treatment sector: Pacemaker revision / system change / explantation (HSMDEF-HSM-REV)

Information about this treatment area (documentation)

Designation	Herzschrittmacher-Revision/-Systemwechsel/-Explantation
Shortcut	09/3
Number of cases	61
Documentation rate	101.64 %

Summary result:

In 3 of 3 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 61

Quality objective achieved
Quality objective not achieved

The results in detail

Hide national result

Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

So rarely did complications occur during repair, replacement or removal of a pacemaker (other than malfunction or displacement of probes: including wound infections)

National result: 1,06 %
Hospital: 0,00 %

Target area: at most 3,10 %

Quality objective achieved

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This is how rarely probes are displaced or malfunction occured during or after pacemaker replacement

National result: 0,78 %
Hospital: Data protection

No information due to data protection

Target area: at most 3,00 %

Quality objective achieved
Why?

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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)

National result: 1,20
Hospital: 0,38

Target area: at most 7,25

Quality objective achieved

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Code ID	121800
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	62
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	unverändert
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	1,06
Target range (reference range)	<= 3,10 %
Confidence interval nationwide (%)	0,87 - 1,29
Hospital confidence interval (%)	0,00 - 5,83
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	52315
Result (%)	Data protection
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	unverändert
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result (%)	0,78
Target range (reference range)	<= 3,00 %
Confidence interval nationwide (%)	0,59 - 1,03
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 severity of illness or concomitant illnesses 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 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.

Code ID	51404
Result	0,38
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	unverändert
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	1,20
Target range (reference range)	<= 7,25 (95. Perzentil)
Confidence interval nationwide	1,05 - 1,38
Hospital confidence interval	0,07 - 2,01
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 Bei diesem Indikator handelt es sich um einen risikoadjustierten Indikator. Eine Risikoadjustierung gleicht die unterschiedliche Zusammensetzung der Patientenkollektive verschiedener Einrichtungen aus. Dies führt zu einem faireren Vergleich, da es patientenbezogene Risikofaktoren gibt (wie zum Beispiel Begleiterkrankungen), die das Indikatorergebnis systematisch beeinflussen, ohne dass einer Einrichtung die Verantwortung für z.B. daraus folgende häufigere Komplikationen zugeschrieben werden kann. Beispielsweise kann so das Indikatorergebnis einer Einrichtung mit vielen Hochrisikofällen fairer mit dem Ergebnis einer Einrichtung mit vielen Niedrigrisikofällen statistisch verglichen werden. Die Risikofaktoren werden aus Patienteneigenschaften zusammengestellt, die im Rahmen der Qualitätsindikatorenentwicklung als risikorelevant eingestuft wurden und die praktikabel dokumentiert werden können. Der Referenzbereich gibt an, in welchem Bereich die Ergebnisse eines Indikators als unauffällig bewertet werden. Eine Einrichtung mit einem Ergebnis außerhalb des Referenzbereichs ist zunächst rechnerisch auffällig, dies zieht üblicherweise eine Analyse im Strukturierten Dialog nach sich. Es ist zu beachten, dass ein Indikatorergebnis außerhalb des Referenzbereichs nicht gleichbedeutend ist mit einer mangelnden Qualität der Einrichtung in dem hier betrachteten Qualitätsaspekt. Die Abweichung kann auch z.B. auf eine fehlerhafte Dokumentation oder auf Einzelfälle zurückführbar sein. Die Bewertung der Qualität wird im Rahmen des Strukturierten Dialogs mit den Einrichtungen vorgenommen. Die Ergebnisse dieses Qualitätsindikators sind aufgrund von Anpassungen der Rechenregel des Indikators nur eingeschränkt mit den Vorjahresergebnissen vergleichbar. Nähere Informationen zu den vorgenommenen Anpassungen können der Beschreibung der Qualitätsindikatoren unter folgendem Link entnommen werden: https://iqtig.org/qs-verfahren/.