Quality Assurance in Perioperative Acute Pain Therapy

The Validity of Claims Data Compared to Registry Data

Not only is severe postoperative pain associated with an increase in short-term complications, but also with an increased risk of significant long-term harm, such as chronic pain and opioid abuse (1). Shortcomings in postoperative pain management in German hospitals have already been demonstrated (2). In Germany, systematic quality assurance has so far only been implemented in the two large pain registries Quality Improvement in Postoperative Pain Management QUIPS (Qualitätsverbesserung in der perioperativen Schmerztherapie) and Network for Safety in Regional Anesthesia and Acute Pain Medicine net-ra (Netzwerk zur Sicherheit in der Regionalanästhesie und Akutschmerztherapie), in both on a voluntary basis. In response to an initiative by scientific medical societies and patient representatives, the Federal Joint Committee (Gemeinsame Bundesausschuss, G-BA) adopted a resolution on 17 September 2020 defining the “Inclusion of a Regulation on the Mandatory Introduction and Implementation of Acute Pain Management Concepts for Adequate Postoperative Pain Therapy” as a quality objective (3). Hospital claims data, primarily collected for administrative purposes, and routine data of the German statutory health insurances (SHI) are increasingly used for quality assurance purposes too, both in the mandatory external quality assurance setting and in voluntary initiatives as well as for healthcare epidemiology studies. All too rarely, however, has the validity of this data for these secondary uses been assessed (4).

In order to also use this data for questions related to postoperative pain therapy, relevant pain management procedures must be adequately represented in the claims data. For this purpose, so far only complex acute pain therapy can be coded using the German operations and procedures classification system OPS (Operationen- und Prozedurenschlüssel) (OPS code 8–919). This code covers special pain therapy for acute pain conditions, for example after surgery, which comprises continuous peripheral/spinal regional anesthesia procedures and patient-controlled analgesia (PCA). Apart from carrying out these procedures, other relevant criteria must also be met: at least two daily visits by an acute-pain service as well as the documentation of at least three aspects of the effectiveness of the treatment (analgesia, symptom intensity, symptom control, …). Despite these personnel and documentation efforts, there is no additional revenue associated with this code. To date, the coding quality of this code has not yet been assessed.

Methods

As part of the LOPSTER project (FKZ: 01VSF19019), which is funded by the G-BA’s Innovation Fund, the validity of OPS 8–919 coding was evaluated by comparing routine data with the documentation in the pain registries QUIPS and net-ra. For this purpose, adult insured persons of BARMER, a statutory health insurance (SHI) fund, were recruited for the study after having undergone in-patient surgery in participating hospitals between March 2021 and March 2022 (QUIPS N = 31, net-ra N = 11) and their QUIPS/net-ra data were obtained. After obtaining informed consents, BARMER provided the SHI data of the included BARMER-insured patients in respect to the corresponding hospital stays and these data were then linked to the registry data, using a study pseudonym (details in the LOPSTER final report of the Innovation Fund at: www.quips-projekt.de/quips/die-lopster-studie). The provision of complex acute pain therapy was operationalized in the two registries based on the documentation of continuous regional analgesia procedures (peripheral, spinal) or patient-controlled intravenous analgesia (PCA) and then compared to the coding of OPS 8–919 from the SHI data.

Results

It was possible to link 1828 QUIPS cases and 538 net-ra cases to their respective SHI data. Table 1 lists the demographic and clinical parameters of the samples analyzed. According to the QUIPS registry documentation, 15% of patients received complex acute pain therapy. In the claims data, on the other hand, the OPS code 8–919 was only coded in 9.6% of cases. The net-ra registry revealed similar figures of 59% versus 37%. Table 2 shows the sensitivity and specificity as well as the positive predictive value (PPV) and negative predictive value (NPV) of the OPS coding.

Table 1

Study sample and distribution of OPS code 8–919 (complex acute pain therapy), comparing registry data and claims data

Table 2

Sensitivity, specificity as well as positive predictive value (PPV) and negative predictive value (NPV) of OPS coding in the two registries compared to claims data of the BARMER statutory health insurance fund

Discussion

The results presented above show that the OPS code 8–919 does not adequately reflect the actual provision of complex acute pain therapy, in particular due to its low sensitivity. The fact that this OPS code is not relevant to revenue generation is certainly a factor contributing to poor coding quality. Not being able to document individual perioperative pain therapy procedures hampers quality assurance approaches. While there are OPS codes for specific procedures (for example, OPS codes 8–910— epidural injection/infusion and 8–915—peripheral injection/infusion), their coding in a perioperative context is explicitly excluded, as the cost of perioperative care is already covered by billing for the procedure performed in the Diagnosis-Related Groups (DRG) system. Thus, the representation of perioperative pain therapy in hospital claims data and SHI routine data is currently neither adequate for healthcare epidemiology studies nor quality assurance purposes. Our findings are in line with other studies, highlighting the problems associated with the secondary use of claims data (4). Our study is the first to examine the validity of OPS coding for perioperative pain therapy by comparing these data with registry data which are primarily collected for quality assurance purposes. While in the net-ra registry the longitudinal data collection ensures that the presence of the additional coding criteria of OPS 8–919 is represented, the presence of these criteria can only be assumed in the QUIPS registry. We believe that the establishment of an external quality assurance procedure by the G-BA is a necessary step to sustainably improve perioperative pain therapy in Germany. The secondary use of routine data could help achieve cost savings, but only if the ability to reflect the procedures of perioperative pain therapy in the OPS catalog is improved and revenue incentives are created for their adequate implementation and coding (5). Outcomes should also be assessed by means of patient-reported outcome measurements (PROMs) or patient-reported experience measurements (PREMs)—at least on a random basis.

Johannes Dreiling, Marcus Komann, Norman Rose, Winfried Meißner, Christine Kubulus, Thomas Volk, Daniel Schwarzkopf

Jena University Hospital, Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-Universität Jena, Jena, Germany (Dreiling, Komann, Rose, Meißner, Schwarzkopf), [e-mail]; Jena University Hospital, Institute of Infectious Diseases and Infection Control, Friedrich-Schiller-Universität Jena, Jena, Germany (Rose); Jena University Hospital, Department of Internal Medicine II, Department of Palliative Medicine, Friedrich-Schiller-Universität Jena, Jena, Germany (Meißner); Saarland University Medical Center, Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Faculty, Saarland University, Homburg/Saar, Germany (Kubulus, Volk)

Conflict of interest statement

WM received consulting fees from Merck, Sanofi, Grünenthal, Tafalgie, Ethypharm, and Mundipharma. He received fees for lectures, presentations and continuing medical education events from Grünenthal, Mundipharma and Kyowa. WM was President of the German Pain Society (Deutsche Schmerzgesellschaft e. V.). TV received fess for lectures, presentations and continuing medical education events from Pajunk. TV was President of ESRA. The remaining authors declare that they have no conflicts of interest.

Manuscript received on 22 January 2025, revised version accepted on 27 March 2025.

Translated from the original German by Ralf Thoene, M.D.

Cite this as:
Dreiling J, Komann M, Rose N, Meißner W, Kubulus C, Volk T, Schwarzkopf D: Quality assurance in perioperative acute pain therapy: The validity of claims data compared to registry data. Dtsch Arztebl Int 2025; 122: 334–5. DOI: 10.3238/arztebl.m2025.0061

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