Germany limits number of hospitals that care for very low birthweight babies

BMJ 2010; 341 doi: (Published 30 November 2010) Cite this as: BMJ 2010;341:c6881
  1. Annette Tuffs
  1. 1Heidelberg

Several German hospitals are launching a legal action against a ruling that will restrict the number of hospitals allowed to care for very low birthweight babies.

The ruling, by the Federal Joint Committee, the regulator of Germany’s statutory health insurance companies, says that only hospitals that have cared for more than 30 babies with birth weights below 1250 g in 2010 will be reimbursed treatment costs by the insurance companies in 2011. This means that only 70 of several hundred hospitals in Germany will be allowed to continue looking after the 8000 very low birthweight babies born in Germany every year.

The German Medical Association and the German Hospital Association have criticised the committee’s decision, saying that there is not enough evidence for introducing the strict regulation. But the ruling has been welcomed by patients’ groups, neonatologists, and health insurance companies, who have been campaigning for the establishment of a network of approved neonatal centres. The current system is said to encourage small hospitals to treat premature babies as substantial reimbursements are provided to the hospitals—more than €90 000 (£75 000; $120 000) in some cases.

The joint committee’s decision follows an evaluation of neonatal care by IQWiG, the German Institute for Quality and Efficiency in Healthcare (sometimes referred to as Germany’s equivalent of the UK National Institute for Health and Clinical Excellence).

IQWiG evaluated 10 studies and said: “Overall the data provide clear indications of a statistical relationship, which shows that an increase in provider volume is associated with a trend towards risk reduction.”

IQWiG recommended that the new regulations should be subject to further evaluation.

The German Hospital Association pointed out that although IQWiG’s evaluation showed a relation between higher provider volume and risk reduction, it didn’t provide evidence for banning smaller volume hospitals from treating highly premature babies, and therefore the joint committee’s decision was illegal.

It has asked the 16 German states to provide the evidence base for restrictions. Closing down facilities in hospitals with fewer than 30 cases a year would jeopardise the care of very low birthweight babies nationally, it said.

Furthermore, the limitation might actually threaten the medical care of mothers and babies at risk, as hospitals would be encouraged to reach the threshold of 30 cases a year and might therefore not try to prolong pregnancy in some cases.

The association also criticised the decision on the grounds that premature babies would have to be transported long distances.

The Association of German University Hospitals, whose members will under the new ruling be the main providers of care for premature babies, said that a more thorough analysis was needed to judge quality of care. Such an analysis could consider, for example, whether qualified gynaecologists and paediatricians were always available in every hospital wanting to care for very low birthweight babies. But it also questioned whether it would be economically efficient to have highly specialised units in more than 300 hospitals.


Cite this as: BMJ 2010;341:c6881