UKM Marienhospital GmbH

Quality results

Treatment sector: Artificial hip joint: first insertion or exchange (HGV-HEP) Explanation

Information about this treatment area (documentation)

Designation	Hüftendoprothesenversorgung
Shortcut	HEP
Number of cases	225
Documentation rate	100 %
Hospital comment	Die Dokumentationsrate wurde krankenhausbezogen berechnet.

Summary result:

In 13 of 13 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 225

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 an artificial hip joint for the first time was made in accordance with the scientific guidelines

Hospital: 97,30 %

Target area: at least 90,00 %

Quality objective achieved

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This is how often the decision to replace an artificial hip joint (or parts of it) was made in accordance with the scientific guidelines

Hospital: 94,44 %

Target area: at least 86,00 %

Quality objective achieved

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This is haow rarely the waiting time for the insertion of an artificial hip joint after a femoral neck fracture was longer than recommended

Hospital: 7,94 %

Target area: at most 15,00 %

Quality objective achieved

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This is how often preventive measures were trained with patients after surgery to avoid another fall

Hospital: 97,85 %

Target area: at least 90,00 %

Quality objective achieved

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Ratio of actual to expected number of patients with general complications who had an artificial hip joint implanted after a femoral neck fracture

Hospital: 1,41

Target area: at most 2,25

Quality objective achieved

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This is how rarely general complications (blood clots, pneumonia, cardiovascular problems) occurred during the planned first-time insertion of an artificial hip joint

Hospital: 3,38 %

Target area: at most 5,77 %

Quality objective achieved

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This is how rarely general complications (blood clots, pneumonia, cardiovascular problems) occurred during operations in which an old artificial hip joint is replaced by a new one (replacement operation)

Hospital: Data protection

No information due to data protection

Target area: at most 20,00 %

Quality objective achieved

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This ist how rarely specific complications occured (wound infections, bleeding, re-fractures) due to the use of an artificial hip joint after a femoral neck fracture

Hospital: Data protection

No information due to data protection

Target area: at most 11,63 %

Quality objective achieved

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This is how rarely specific complications occured (wound infections, bleeding, new fractures) due to the initial insertion of an artificial hip joint

Hospital: 0,00 %

Target area: at most 8,01 %

Quality objective achieved

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Ratio of actual to expected number of patients who experienced specific complications when replacing an old artificial hip joint with a new one (or when replacing individual components)

Hospital: 0,44

Target area: at most 2,02

Quality objective achieved

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Ratio of actual to expected number of patients who experienced problems with the implant (misalignment, displacement, material fracture, etc.) when replacing an old artificial hip joint with a new one.

Hospital: 1,10

as rarely as possible

Evaluation is not available

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Ratio of actual to expected number of patients who experienced wound infections, vascular injuries, nerve damage, post-operative bleeding and other soft tissue complications when replacing an old artificial hip joint with a new one.

Hospital: 0,00

as rarely as possible

Evaluation is not available

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Ratio of the actual number to the previously expected number of patients who could not walk 50 metres when discharged from hospital (individual risks of the patients were taken into account)

Hospital: 1,73

Target area: at most 2,42

Quality objective achieved

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This is how rarely patients died during their hospital stay after having an artificial hip joint implanted

Hospital: 0,00 %

Sentinel Event

Quality objective achieved

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Ratio of actual to expected number of patients who received an artificial hip joint after a fracture of the neck of the femur and died during the operation.

Hospital: 1,83

as rarely as possible

Evaluation is not available

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Ratio of the actual number to the previously expected number of patients in whom the artificial hip joint or individual parts were replaced (based on the period of 90 days after the operation in which the artificial hip joint was first inserted - individual risks of the patients were taken into account)

Hospital: 1,38

Target area: at most 2,27

Quality objective achieved

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Code ID	54001
Result (%)	97,30
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	148
Events observed	144
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 (%)	97,67
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	97,60 - 97,74
Hospital confidence interval (%)	93,26 - 98,94
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. 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	54002
Result (%)	94,44
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	18
Events observed	17
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 (%)	91,85
Target range (reference range)	>= 86,00 %
Confidence interval nationwide (%)	91,46 - 92,23
Hospital confidence interval (%)	74,24 - 99,01
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 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. Due to adjustments to the QS filter, the results of this quality indicator cannot be compared with the previous year's results. 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	54003
Result (%)	7,94
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	63
Events observed	5
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 (%)	9,27
Target range (reference range)	<= 15,00 %
Confidence interval nationwide (%)	9,06 - 9,49
Hospital confidence interval (%)	3,44 - 17,27
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 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	54004
Result (%)	97,85
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	186
Events observed	182
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 (%)	96,97
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	96,89 - 97,04
Hospital confidence interval (%)	94,60 - 99,16
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. 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	54015
Result	1,41
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	7
Anticipated events	4,95
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	1,01
Target range (reference range)	<= 2,25 (95. Perzentil)
Confidence interval nationwide	0,99 - 1,03
Hospital confidence interval	0,70 - 2,69
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 structure 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 it being possible to attribute responsibility for e.g. resulting more frequent complications to one facility. With the help of risk adjustment, the quality outcome of, for example, an institution with many high-risk cases can be statistically compared more fairly with the quality outcome of an institution 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 establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered suspicious. 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 incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	54016
Result (%)	3,38
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	148
Events observed	5
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 (%)	1,36
Target range (reference range)	<= 5,77 % (95. Perzentil)
Confidence interval nationwide (%)	1,31 - 1,41
Hospital confidence interval (%)	1,45 - 7,66
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. For example, the severity of illnesses or concomitant diseases of the patients have an impact 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. 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	54017
Result (%)	Data protection
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 (%)	7,84
Target range (reference range)	<= 20,00 % (95. Perzentil)
Confidence interval nationwide (%)	7,44 - 8,26
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. For example, the severity of illnesses or concomitant diseases of the patients have an impact 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. Due to adjustments to the QS filter, the results of this quality indicator cannot be compared with the previous year's results. 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	54018
Result (%)	Data protection
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 (%)	4,53
Target range (reference range)	<= 11,63 % (95. Perzentil)
Confidence interval nationwide (%)	4,37 - 4,69
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. For example, the severity of illnesses or concomitant diseases of the patients have an impact 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. 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	54019
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	148
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 (%)	2,27
Target range (reference range)	<= 8,01 % (95. Perzentil)
Confidence interval nationwide (%)	2,21 - 2,34
Hospital confidence interval (%)	0,00 - 2,53
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. For example, the severity of illnesses or concomitant diseases of the patients have an impact 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. 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	54120
Result	0,44
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	1,02
Target range (reference range)	<= 2,02 (95. Perzentil)
Confidence interval nationwide	0,98 - 1,06
Hospital confidence interval	0,08 - 2,02
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 structure 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 it being possible to attribute responsibility for e.g. resulting more frequent complications to one facility. With the help of risk adjustment, the quality outcome of, for example, an institution with many high-risk cases can be statistically compared more fairly with the quality outcome of an institution 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 establishes a benchmark for the evaluation of facilities. A result outside the reference range is initially considered suspicious. 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 incorrect documentation, medical specificity of the patient collective or individual cases. The evaluation of quality is carried out within the framework of the defined procedure in the comments procedure. More detailed information on reference areas can be found at the following link: https://iqtig.org/das-iqtig/grundlagen/methodische-grundlagen.

Code ID	191800_54120
Result	1,10
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	1,05
Target range (reference range)
Confidence interval nationwide	0,99 - 1,11
Hospital confidence interval	0,20 - 5,10
Reference infection	No
Type of value	KKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	1
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 results of which are 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 presenting the quality of care. More detailed information on ratios can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	191801_54120
Result	0,00
Evaluation through structured dialogue
Population	17
Events observed	0
Anticipated events	1,43
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	1,00
Target range (reference range)
Confidence interval nationwide	0,95 - 1,05
Hospital confidence interval	0,00 - 2,19
Reference infection	No
Type of value	KKez
Relation to the procedure	DeQS
Reference to other QA results
Sorting	2
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 results of which are 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 presenting the quality of care. More detailed information on ratios can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept.

Code ID	54012
Result	1,73
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	207
Events observed	15
Anticipated events	8,67
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	1,02
Target range (reference range)	<= 2,42 (95. Perzentil)
Confidence interval nationwide	1,00 - 1,04
Hospital confidence interval	1,06 - 2,77
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. the following more frequent complications can be attributed to it. 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	54013
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	137
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 (%)	0,05
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,04 - 0,06
Hospital confidence interval (%)	0,00 - 2,73
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 From the federal data, risk factors of patients could be determined that significantly influence their risk of dying during inpatient stay. Then, in a second step, the 10% of the patients for whom this risk is particularly low could be determined. These form the population for this quality indicator as the 10% patients with low probability of death. It should be noted that this computational result may not be influenced exclusively by the respective institution. For example, the severity of illnesses or concomitant diseases of the patients have an impact 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. 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	191914
Result	1,83
Evaluation through structured dialogue
Population	62
Events observed	4
Anticipated events	2,18
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result	1,07
Target range (reference range)
Confidence interval nationwide	1,04 - 1,10
Hospital confidence interval	0,72 - 4,39
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 results of which are 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 presenting the quality of care. More information on indicators can be found at the following link: https://iqtig.org/veroeffentlichungen/kennzahlenkonzept. 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, an institution with many high-risk cases can be statistically compared more fairly with the quality outcome of an institution 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.

Code ID	10271
Result	1,38
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	221
Events observed	5
Anticipated events	3,63
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	eingeschränkt/nicht vergleichbar
National result	0,83
Target range (reference range)	<= 2,27 (95. Perzentil)
Confidence interval nationwide	0,80 - 0,86
Hospital confidence interval	0,49 - 2,96
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. the following more frequent complications can be attributed to it. 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 represents both events such as Complications that occur before discharge from a hospital, as well as events that occur after discharge but can still be related to the implantation.