Reservations Regarding the Suitability of the DRG System

In our opinion, the hospital discharge data (diagnosis related group [DRG] statistics) that provide the basis for the analysis (1) are not sufficiently suitable for assessing the actual morbidity and mortality after herniotomies. Most hernias are found in the catalogue of outpatient procedures according to §115b SGB [German Social Code Book] V. Outpatient hernia repairs account for about 20% of all hernia repairs in Germany (2). Similarly, the different surgical techniques with their completely different risk profiles were not taken into account. Primary hernias can differ enormously and are therefore difficult to represent in the DRG system (3). In some instances, more than 60 different surgical procedures are subsumed under one DRG, but in Europe, there are only three or four different ways of coding herniotomies in DRGs on average. This does not seem sufficient for generating relevant data (4). The authors’ conclusion that the preoperative identification of risk could be optimized is consequently only partly valid. In the DRG-based analysis, it is impossible to differentiate between elective procedures and emergency operations. A highly acute incarcerated hernia, which according to the literature presents itself in about 5% of all cases (2), requires immediate action and is associated with substantially higher fatality rate than an elective procedure, which allows for individual preoperative optimization, as suggested. However, in rare cases, so-called watchful waiting is associated with a higher risk for hernia patients, but results in a different DRG classification in inpatients, which is not taken into account in the presented data. It is our view that the DRG system as a hospital reimbursement system that was introduced in the context of an economy drive in Germany’s healthcare system (3) still does not allow valid conclusions about clinical procedures, despite many attempts to optimize it. In our opinion, hernia registries are a more appropriate instrument.