Johanniter-Krankenhaus Geesthacht GmbH

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Quality results

Treatment sector: Pacemaker: First use (09/1) Explanation

Information about this treatment area (documentation)

Designation	Herzschrittmacher-Implantation
Shortcut	09/1
Number of cases	12
Documentation rate	100 %
Hospital comment	Die Dokumentationsrate wurde krankenhausbezogen berechnet.

Summary result:

In 12 of 12 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 12

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

Hospital: 100,00 %

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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The choice of the pacemaker system was appropriate according to scientific standards. This concerns pacemaker systems that should be used in most cases

Hospital: 100,00 %

as often as possible

Evaluation is not available

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The choice of the pacemaker system was appropriate according to scientific standards. This concerns pacemaker systems that should be used in less than half of cases

Hospital: 0,00 %

as rarely as possible

Evaluation is not available

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The choice of the pacemaker system was appropriate according to scientific standards. This concerns specialist pacemaker systems that should only be used in individual cases

Hospital: 0,00 %

Target area: at most 10,00 %

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: 100,00 %

Target area: at least 60,00 %

Quality objective achieved

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Hospital: Data protection

No information due to data protection

Target area: at most 3,44

Quality objective achieved

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Various measurements during the operation have shown that the pacemakers wires were functioning properly

Hospital: 81,82 %

Target area: at least 90,00 %

Quality objective achieved
Why?

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Hospital: 0,00 %

Target area: at most 2,60 %

Quality objective achieved

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Unintentional change of position or malfunction of the pacemakers wires (probes)

Hospital: 0,00 %

Target area: at most 3,00 %

Quality objective achieved

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Hospital: 100,00 %

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: Data protection

No information due to data protection

Target area: at most 4,29

Quality objective achieved
Why?

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So rarely did the pacemaker housing have to be replaced within four years after initial insertion because the battery was exhausted (applies to pacemakers with one or two leads)

Hospital: 0,00 %

Sentinel Event

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: Data protection

No information due to data protection

Target area: at most 2,77

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: 0,00

Target area: at most 6,14

Quality objective achieved

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Code ID	101803
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	12
Events observed	12
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 (%)	94,19
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	94,02 - 94,36
Hospital confidence interval (%)	73,54 - 100,00
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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

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	12
Events observed	12
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	98,53
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	98,43 - 98,62
Hospital confidence interval (%)	73,54 - 100,00
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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	54141
Result (%)	100,00
Evaluation through structured dialogue
Population	12
Events observed	12
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	96,65
Target range (reference range)
Confidence interval nationwide (%)	96,51 - 96,78
Hospital confidence interval (%)	73,54 - 100,00
Reference infection	No
Type of value	TKez
Relation to the procedure	QSKH
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 is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the supply process and thus increase transparency and the information content. More information on the key figure concept can be found in the following link; https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. The system choice for pacemaker implantations is evaluated based on the current guidelines for pacemaker and cardiac resynchronization therapy of the European Society of Cardiology (Brignole et al. 2013). First choice systems are referred to as such because in the majority of cases they represent the correct system choice. If first choice systems are not implanted in the majority of cases, this can indicate problems with the selection of the appropriate system. 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	54142
Result (%)	0,00
Evaluation through structured dialogue
Population	12
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	0,10
Target range (reference range)
Confidence interval nationwide (%)	0,07 - 0,12
Hospital confidence interval (%)	0,00 - 26,46
Reference infection	No
Type of value	TKez
Relation to the procedure	QSKH
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 is a transparency measure. Transparency indicators do not meet the formal criteria of a quality indicator because they have no reference area and therefore do not trigger a structured dialogue. The results are independent and are not directly linked to a quality indicator. However, transparency indicators indicate essential quality aspects of the supply process and thus increase transparency and the information content. More information on the key figure concept can be found in the following link; https://www.g-ba.de/downloads/39-261-3380/2018-06-21_Qb-R_Freigabe-IQTIG-Bericht_Kennzahlen_inkl-Anlagen.pdf. The system choice for pacemaker implantations is evaluated based on the current guidelines for pacemaker and cardiac resynchronization therapy of the European Society of Cardiology (Brignole et al. 2013). Second choice systems are referred to as such because in the majority of cases they do not represent the correct system choice. If second-choice systems are implanted in the majority of cases, this can indicate problems with the selection of the appropriate system. 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	54143
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	12
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	1,78
Target range (reference range)	<= 10,00 %
Confidence interval nationwide (%)	1,68 - 1,88
Hospital confidence interval (%)	0,00 - 26,46
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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 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). Third choice systems are referred to as such, since they only represent the correct system choice in individual cases. However, if 3rd choice systems are implanted very frequently, this can indicate problems with the selection of the appropriate system. 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 (%)	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	12
Events observed	12
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	88,94
Target range (reference range)	>= 60,00 %
Confidence interval nationwide (%)	88,73 - 89,15
Hospital confidence interval (%)	73,54 - 100,00
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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	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	unverändert
National result	0,87
Target range (reference range)	<= 3,44 (95. Perzentil)
Confidence interval nationwide	0,85 - 0,89
Hospital confidence interval	0,15 - 3,45
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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

Code ID	52305
Result (%)	81,82
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. (U32)
Population	44
Events observed	36
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	95,31
Target range (reference range)	>= 90,00 %
Confidence interval nationwide (%)	95,23 - 95,39
Hospital confidence interval (%)	67,35 - 91,85
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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	12
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 (%)	1,05
Target range (reference range)	<= 2,60 %
Confidence interval nationwide (%)	0,98 - 1,13
Hospital confidence interval (%)	0,00 - 26,46
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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

Code ID	52311
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	12
Events observed	0
Anticipated events	0,00
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	1,59
Target range (reference range)	<= 3,00 %
Confidence interval nationwide (%)	1,50 - 1,68
Hospital confidence interval (%)	0,00 - 26,46
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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 (%)	100,00
Evaluation through structured dialogue
Population	12
Events observed	12
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	55,05
Target range (reference range)
Confidence interval nationwide (%)	54,68 - 55,41
Hospital confidence interval (%)	73,54 - 100,00
Reference infection	No
Type of value	TKez
Relation to the procedure	QSKH
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

Code ID	51191
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. (U32)
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	unverändert
National result	1,11
Target range (reference range)	<= 4,29 (95. Perzentil)
Confidence interval nationwide	1,05 - 1,18
Hospital confidence interval	1,07 - 25,44
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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	2190
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	94
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 (%)	0,03
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,02 - 0,04
Hospital confidence interval (%)	0,00 - 13,29
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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

Code ID	2194
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	unverändert
National result	1,01
Target range (reference range)	<= 2,77 (95. Perzentil)
Confidence interval nationwide	0,97 - 1,04
Hospital confidence interval	0,07 - 5,74
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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	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	18
Events observed	0
Anticipated events	0,05
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result	1,04
Target range (reference range)	<= 6,14 (95. Perzentil)
Confidence interval nationwide	0,90 - 1,19
Hospital confidence interval	0,00 - 69,50
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
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."