We appreciate the suggestions that Dr. Silvay has pointed out in his letter to the editor in response to our article about the Leipzig Fast-Track Concept.1The concept of a preevaluation clinic as described by Dr. Silvay is a powerful tool to optimize safety for the patients and to avoid unnecessary expenditures.2 

But one has to differentiate costs incurring for the health system itself and reimbursement of the actual costs for the individual hospital by the health care system. To reduce costs for the individual hospital significantly, one has to look for the real cost driver during the hospital stay of the patient. One of the most intensive cost drivers in each hospital is the intensive care unit.3With our fast-track concept, we can completely avoid the stay in the intensive care unit for most of the planned fast-track patients. Reimbursement for preclinical evaluation of the patient is not possible for hospitals in the German health care system. The German health care system is based on diagnosis-related groups, a classification of hospital cases expected to have similar hospital resource use.4Therefore, the hospital gets a fixed fee, for example, for the surgical treatment of aortic valve stenosis, regardless of the actual costs incurred, based on the principle diagnosis, surgical procedure used, age of patient, and expected length of stay in hospital. Preoperative evaluation of the patient is usually performed by the physician, who transfers the patient to the hospital for treatment. Unevaluated diagnostics are performed in the hospital the day prior to surgery after admission to the ward. The admission ward itself is not a cost-intensive unit of the hospital; as long as the patient does not exceed the mean length of stay in the hospital as defined in the diagnosis-related groups, the hospital will save money. However, treatment in a preevaluation clinic, as previously mentioned, is not covered by the diagnosis-related group system. Often we receive patients who have come from a great distance, and hence prior admission to the preevaluation clinic would add to the cost of the hospital. This may be different to the reimbursement practice in the United States.

However, we agree with Dr. Silvay that a combination of a preevaluation clinic and the Leipzig Fast-Track concept will enhance patient satisfaction throughout the surgical process and can lead to further cost reduction for the health care system itself.

*University of Leipzig, Leipzig Heart Center, Leipzig, Germany. joerg.ender@medizin.uni-leipzig.de

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Silvay G, Flynn B, DePerio M, Hughes I: Characteristics of preanesthetic clinic for day admission cardiac and major vascular surgery. Anesth Analg  2008; 106(suppl. 3):S–37
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Roeder N, Rochell B, Juhra C: Empirical comparison of DRG variants using cardiovascular surgery data: initial results of a project at 18 German hospitals. Aust Health Rev 2001; 24:57–80