The Utilization of Ambulatory Emergency Care and Unplanned Hospitalizations in Germany, 2010–2019

An increase in the number of patients presenting to emergency departments although they do not necessarily require emergency treatment has long been considered a sign of mismanagement in emergency care. The legislator has already made adjustments to the legal requirements for emergency care several times since 2015, and further reform plans have been in place. The impact of statutory regulations already implemented has so far not been fully appreciated, although there are initial signs of a reversal of the trend in the utilization of ambulatory emergency care (1). The present observational study therefore investigated how utilization of ambulatory emergency care and unplanned hospitalizations have changed over the years from 2010 to 2019.

Methods

The outpatient billing data of 16 Associations of Statutory Health Insurance Physicians (KVs) (excluding Bremen) for the years 2010 to 2019 were used as the underlying database. All treatment cases with at least one fee schedule item (GOP) from the emergency case Section 1.2 of the Standardized Schedule of Fees (EBM) were regarded as ambulatory emergencies. A distinction between during and outside office hours has only been possible for the first time as of the fourth quarter of 2014 with the introduction of appropriately differentiated GOPs. A treatment case was considered to have been provided during office hours if GOP 01205, 01210 or 01214 was invoiced. Cases for which GOP 01207, 01212, 01216 or 01218 was invoiced were considered to have been provided outside office hours. In addition, the development of DRG cases (diagnosis-related groups) with “emergency” as the reason for admission was analyzed on the basis of the DRG statistics for the years 2010 to 2019. These are unplanned hospitalizations, the number of which is made up of both referred emergencies and self-referrals. It was not possible to create a link between outpatient data and DRG data. The year 2020 was not included due to the extraordinary impact of the pandemic.

Results

The Figure shows that the total number of emergencies has been in gradual decline since 2018 and hospital emergencies already since 2016. However, while ambulatory emergencies in hospitals have been decreasing, the number of hospitalizations with “emergency” as the reason for admission continues to increase. The total number of ambulatory emergencies initially increased gradually between 2010 and 2018 from 17.4 million to 19.5 million cases and decreased to 19 million in 2019, with ambulatory emergencies in emergency departments already showing a slight decrease since 2016 and during office hours even since 2015 (Table). The total number of emergencies in hospitals increased from 15.3 million to 19.3 million between 2010 and 2016, and then decreased to 19 million in 2019. Unplanned admissions have increased continuously (Figure).

Figure

Number of emergencies 2010–2019

Table

Number of outpatient emergencies, grouped according to utilization during and outside office hours

Discussion

The present results indicate a change in the utilization of ambulatory emergency care since 2016. Several factors may be considered as reasons for this. For example, declines during office opening hours may well be due to more stringent billing audits by the KVs. In addition, more than 830 out-of-hours health centers have been set up by KVs in or at hospitals since 2016, which may have contributed to relieving the pressure on emergency departments. The expansion of the appointment service centers, together with increasing awareness of the 116117 patient service telephone number, may also have contributed to this development. However, the implementation of 24/7 accessibility and structured initial assessment by telephone did not start until mid-2019. Furthermore, there could be a connection between falling ambulatory case numbers in emergency departments and the further increase in the number of emergency hospitalizations. Whether hospitalizations admitted as “emergency” are genuine emergencies has been called into serious question elsewhere (2). In this regard, the German Council of Economic Experts has already pointed out that the remuneration gap between DRG and EBM has created a financial incentive (3).

One limitation of the present analysis is that the database used does not contain any cases that were invoiced within the framework of Section 115b of the German Social Code, Book V (operations that can be performed on an outpatient basis and other interventions that replace inpatient procedures) or as cases billed via the Germany institutions for statutory accident insurance and prevention. Data of privately insured persons or persons insured abroad are also not included. In addition, acute cases that were directed to a doctor’s office during office hours are not invoiced as emergencies using the emergency care GOP, but via the regular basic flat rate for insured persons. So these were not included in the present study. This circumstance must also be taken into account when the numbers of ambulatory emergencies during opening hours of emergency departments and those of out-of-hours medical services are considered in relation to each other. Acute cases normally cared for in doctors’ surgeries amount to considerably more than the cases that are covered by emergency GOPs. An evaluation of the cases treated by statutory health insurance physicians with diagnoses corresponding to the cardinal symptoms listed in the software known as Structured Medical Assessment in Germany (SmED) showed that approximately 196 million acute cases are treated by statutory health insurance physicians per year during office opening hours (1).

Although the present study shows a positive trend in the extent of outpatient emergency department utilization, more initiatives are called for to further address the problem of overburdened emergency departments. The reasons underlying this utilization provided in patient surveys (4, 5) indicate that patients who have already presented to emergency departments are often still in need of an immediate alternative service. Appropriate proposals to further relieve the emergency departments could be made via partner or cooperation practices that also accept acute patients during office opening hours, via the extension of the medical out-of-hours services on-site at hospitals, or via the central service number 116 117. The prerequisite for this would require suitable patients being identified quickly and reliably before more complex diagnostics are carried out.

Sandra Mangiapane, Thomas Czihal, Dominik von Stillfried
Central Research Institute of Ambulatory Health Care in Germany (Zi), Berlin, [e-mail]

Conflict of interest statement
The employer (Zi) is predominantly financed by grants from the Associations of Statutory Health Insurance Physicians (KVs). It is committed to providing scientific support for the service guarantee of the Associations of Statutory Health Insurance Physicians.

Manuscript received on 07 December 2021, revised version accepted on 23 February 2022

Translated from the original German by Dr. Grahame Larkin, MD

Cite this as:
Mangiapane S, Czihal T, von Stillfried D: The utilization of ambulatory emergency care and unplanned hospitalizations in Germany, 2010–2019. Dtsch Arztebl Int 2022; 119: 425–6. DOI: 10.3238/arztebl.m2022.0160

References

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2. Schreyögg J, Bäuml M, Krämer J, Dette T, Busse R, Geissler A: Forschungsauftrag zur Mengenentwicklung nach § 17b Abs. 9 KHG. 2014. https://www.g-drg.de//content/download/4861/38231/version/2/file/Endbericht+zum+Forschungsauftrag+gem.+%C2%A7+17b+Abs.+9+KHG+%28Druck%29.pdf?pk_campaign=Forschungsauftrag&pk_kwd=Endbericht%20Druck (last accessed on 17 February 2022).

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