In many hospitals, the radiology department is seen only as a service that provides diagnostic information for therapies carried out in other departments. Klinikum Stuttgart in Germany, however, has taken a different approach by combining diagnostic and therapeutic radiology in one department with admitting privileges.
Photos: Thomas Bernhardt
A Comprehensive Approach
For several years Götz Martin Richter, MD, Director of the Center of Radiology at Klinikum Stuttgart in Germany, worked at another hospital in Germany where time-consuming and inefficient consultation between departments was a source of real annoyance: “Whenever I wanted to act, I had to go to great lengths to get other departments to agree on what should be done when and how.” Now Richter performs a variety of procedures for which he is in charge of everything from initial patient consultation and admittance to discharge and clinical follow-up.
A More Streamlined Process between Departments
Klinikum Stuttgart does things differently. Its radiology department performs a wide variety of interventional therapies as well as diagnostic procedures. This combination of diagnostic and interventional radiology (IR), along with the hospital’s strong interdisciplinary approach, guarantees that patients needing oncological or surgical observation and care are treated in the conventional way. Those who can be directly referred to IR are then treated by Richter’s team alone. Interventional therapies at Klinikum Stuttgart include oncological tumor treatment (TACE, SIRT, thermal ablation), vascular interventions (EVAR, lysis, stenting, special recanalization procedures), and interventional treatment of benign tumors such as uterine fibroids and AV malformations.
A Department with its own Beds
The department’s success as a treatment provider is underpinned by its approach to bed management. “We are one of the few radiology clinics in Germany with our own beds,” Richter says. The department currently has nine. Richter usually goes through the procedure with the patient before the intervention, and he or she returns home afterwards. Only on the actual day of the intervention is the patient admitted and allocated a bed. Following the procedure, the patient stays one night or more and is discharged as soon as possible.
Patients Spend Less Time in Hospital
As a result, hospital stays are shorter for Richter’s patients. According to Anne Bickelmann, Center Director for Economics at Klinikum Stuttgart, patients spend an average of one night fewer in hospital than those at facilities that have no dedicated beds and where staff have to confer with inpatient wards to decide when patients can be discharged and by whom. “At other hospitals, the patient also has to stay the night before the procedure. We can keep our beds free for patients who really need them,” Bickelmann explains. This optimizes patient satisfaction and reduces the amount of time spent in hospital.
Costs are 30% Lower Than in Other Hospitals
This holistic approach that gives the department control over its own beds is already providing financial benefits, having markedly improved cost-effectiveness. “The costs for our own interventional patients are currently 30% lower than the average in other radiology departments in Germany,” Richter explains. This has been achieved largely by deploying staff efficiently and keeping a close eye on infrastructure costs. Since costs have been kept in check, Richter has been able to invest in high-end angiography equipment, such as Siemens’ unique robot-assisted Artis zeego, while maintaining a profit margin of 6%.
Patient Satisfaction Exceeds 90%
The success of the Stuttgart model is also reflected in exceptional patient satisfaction rates. Patients find it reassuring that the interventional radiologist treating them is in charge of their care before, during, and after interventional treatment. “More than 90% of patients are satisfied with us and say that they would recommend us to other people,” Richter says. A survey of women who received interventional treatment for uterine myomas found that almost 96% were satisfied with the medical care they had received, compared with the national average of 83% for UFE treatment in Germany.
Germany’s DRG System
The Stuttgart model was developed within Germany’s DRG (diagnosis-related groups) system, which promotes competition and cost-effectiveness. Since 2003, payments in Germany have been calculated on a flat-rate basis, rather than by length of hospital stay. A treatment fee is defined for every illness and is the same for all hospitals. Taking this base rate as the starting point, cases are then assigned to different groups. Hospitals receive a multiple of the base rate for difficult procedures, and are payed considerably less than the base rate for straightforward cases.
Patient and Cost Management are Key
Comparing the case mix index (CMI) of Klinikum Stuttgart’s IR patients with other German hospitals provides even more impressive evidence of the institution’s financial success. Within four years, the CMI value for radiology procedures in Stuttgart has increased by 50% to 1.5. Values above 1.0 indicate that hospitals are treating more complex cases. Anne Bickelmann attributes the leap in CMI to improved returns and to the new types of therapy that Richter has introduced. This is particularly true for complex interventions. In other words, effective patient and cost management are key to achieving economic benefits even in complex cases.
A Model for Other Countries
Anne Bickelmann is convinced that the model can be replicated abroad. If radiology evolves from a purely diagnostic tool to become a provider of clinical treatment, it will open up new therapeutic options and care pathways for all hospitals. Richter agrees: “Optimizing processes makes it easier to contain costs and increase treatment success. The more coding and billing that is done in one place, the better.” In order to ensure correct invoicing and reimbursement, he has a dedicated staff member tasked with ensuring that the proper DRG coding is assigned to procedures carried out in the radiology department.
Bed Management Leads to Greater Transparency
Richter and his team are keen to develop their successful approach to bed management. Given the ever-changing nature of healthcare reimbursement, the Stuttgart model of a radiology department with its own beds could help hospitals financially, as it provides greater transparency in terms of spending and makes it easier to control costs. “We are in a position to expand further and could use more beds,” says Richter with a smile.
Interventional Radiology – New Primary Specialty & Residency
The role of the interventional radiologist is also changing in the United States. In 2012, the American Board of Medical Specialties approved interventional radiology (IR) as a primary specialty, separate from diagnostic radiology (DR). The distinction was based on the unique combination of skills in diagnostic imaging, image-guided procedures, and non-procedural patient care required of interventional radiologists.
In 2014 the Accreditation Council for Graduate Medical Education (ACGME) approved a dedicated curriculum that leads to IR/DR certification by the American Board of Radiology and includes a dedicated IR residency.
This is good news for interventional radiologists, hospitals, and their patients, as it will standardize quality of care by setting educational benchmarks and requiring physicians to document their qualifications. “In practice, interventional radiologists have had admitting privileges at hospitals like mine since 1991,” says Alan Matsumoto, MD, Chair of the Department of Radiology and Medical Imaging at the University of Virginia, “but this recognition of interventional radiology as a distinct clinical specialty in the U.S. is a huge opportunity.”
Yet interventional radiologists are different. In addition to being imaging and procedural specialists, they are also directly involved in patient care. “We perform inpatient consultations, operate outpatient clinics, admit and discharge patients, and provide clinical care including medical follow-up,” explains Matsumoto. That makes it all the more important to ensure that the training for young physicians includes critical care rotations, experience with outpatient clinics and inpatient clinical consultations, and responsibility for admitting and discharging patients.
Not everyone is as excited as Matsumoto about the new status of the discipline. Surgeons may find interventional radiologists vying for business. Certain procedures, such as iliac stenting, can be performed either in an operating room or in an interventional suite. Matsumoto believes that we can expect significant changes in care pathways.