Gaps in public health surveillance of elective surgery: a national analysis of inpatient data, COVID-19 impact, and coding validity in Germany (2006-2023).

BACKGROUND

Administrative inpatient datasets are cornerstone tools for health surveillance, yet their validity in tracking elective, self-pay surgical markets remain poorly defined. This study evaluates the utility of nationwide inpatient data for monitoring aesthetic surgery by quantifying 18-year trends, assessing the COVID-19 pandemic's impact, and benchmarking hospital capture rates against national estimates to identify critical public health surveillance gaps.

METHODS

We conducted a descriptive longitudinal epidemiologic analysis of mandatory German hospital quality reports (2006-2023). Four high-volume procedures (liposuction, blepharoplasty, breast augmentation, and abdominoplasty) were identified via procedure-specific codes. To evaluate diagnostic validity, we analyzed the usage of ICD-10 code Z41.1 ("Procedures for purposes other than remedying health states"). Inpatient volumes were benchmarked against ISAPS national estimates to determine the "hospital share" of the total market.

RESULTS

Between 2006 and 2023, 352,468 inpatient procedures were recorded. Annual volumes tripled from 11,593 to 33,170. While inpatient liposuction (+611%) and abdominoplasty (+424%) surged, breast augmentation declined by 33%. Liposuction volumes showed no significant immediate 2020 level decline in segmented analysis and continued to increase during the post-pandemic period. Benchmarking suggested limited hospital visibility of the broader national aesthetic-surgery market: by 2023, hospitals captured only 2.0% of national breast augmentations and 13.5% of liposuctions. ICD-10 Z41.1 was utilized in only 0.4% of cases, suggesting limited utility as an indication-specific surveillance marker.

CONCLUSIONS

While hospital data serve as a vital sentinel for high-complexity cases, the massive discrepancy between inpatient volumes and national estimates highlights a large data gap in elective surgery surveillance. The limited use of Z41.1 suggests that current diagnostic coding frameworks are insufficient, on their own, for monitoring elective self-pay procedures. Transitioning to integrated, cross-sectoral registries and ICD-11 is essential for accurate epidemiological mapping and surgical workforce planning.