Evidence of quality-result in BG-therapy - Standardised computer-supported evaluation of medical expertises for purposes of quality assurance and improvement

Status:

completed 10/2010

Aims:

Comprehensive evaluation of the results of operative and conservative treatment and of case management in work-related calcaneal fractures, especially the structural and functional results of treatment, disability, abstract measure of disability (MdE), the duration of absence from work, work-related rehabilitation and costs as well as the determining factors.

Activities/Methods:

All cases of work-related calcaneal fractures that occurred from July 1, 2005 to July 31, 2008 in Hamburg, Schleswig-Holstein, Bremen, the North-Western part of Mecklenburg-Western Pomerania and the Northern part of Lower Saxony (postal area codes 18 - 29) in the scope of the participating regional workmen's compensations insurers were investigated using computer-assisted evaluation of medical expertises and disability management data. For this purpose an injury specific registration sheet to be filled in by the disability managers was developed. The sheet includes data about the classification of the injury (according to the DGUV-code), the treatment, complications, absence from work, vocational rehabilitation, MdE and costs. In those cases in which an impairment evaluation was carried out an additional injury specific registration sheet with data about the classification of the injury (according to the modified ASIF-classification of Kuner et al.), the treatment, complications, and the structural and functional outcome was filled in by the medical experts. A total of 452 cases (438 one-sided and 14 both-sided fractures) were evaluated, including 169 cases (158 onesided and 11 both-sided fractures) in which an impairment evaluation had been documented.

Results:

The methodology used in this study has exemplary character and has proven itself a suitable and feasible instrument for measuring the outcome quality in the setting of work related injuries. The strongest determinant of outcome was the severity of the original injury which was well represented by the modified ASIF classification (Association for the Study of Internal Fixation) used in the registration sheets filled in by the medical experts. The encoding according to the DGUV-code used by the disability managers, however, provided only insufficient information about the severity of the injuries incurred.
The results of this study support the opinion that a revision of the DGUV encoding systems is advisable. In the studied patient population the outcome quality in terms of structural and functional results, duration of absence from work, MdE and vocational rehabilitation is up to the results published in the literature and in some aspects tended to be more favourable. Over 80 % of the displaced intraarticular calcaneal fractures were treated operatively. In these cases a remaining MdE of less than 20 % was achieved in 16.8 %. In the subgroup treated operatively at the BG-Unfallkrankenhaus Hamburg an MdE of less than 20 % could be attained in 28 %. Most commonly locked-screw plate fixation was used. In contrast, an MdE of 20 % or more remained in all displaced intraarticular calcaneal fractures which were treated non-operatively. In the surveillance of after-treatment special attention should be turned to the timeline of the successive increases in weight-bearing that should be implemented between the end of the 6th and 12th week postoperatively, thus utilizing a great potential for shortening the duration of medical treatment and absence from work and decreasing overall costs. The routine use of heel relief orthoses in one-side calcaneal fractures did not result in a shortening of time absent from work.

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