# Cooperative spatial modelling of hospital compliance with minimum caseload requirements

## TL;DR

This study models how hospitals in Germany can cooperate to meet minimum caseload requirements while balancing quality and accessibility of care.

## Contribution

The study introduces a spatial model that incorporates hospital intentions and motivations into MCR compliance decisions.

## Key findings

- Hospital grouping results show varying cooperation needs across different procedures in Germany.
- A significant percentage of hospital groups required no cooperation for MCR compliance.
- The model supports flexible policy testing and informs regional decision-making.

## Abstract

Minimum caseload requirements (MCRs) ensure medical treatment quality but may negatively affect spatial accessibility to health care. Previous studies optimised the caseload distribution via spatial models, with a focus on balancing spatial concentration and accessibility with centralised case redistribution models. This study seeks to capture hospitals as active participants in MCR policy decisions by incorporating their intentions and motivations regarding MCRs within their spatial context, considering current caseloads and neighbouring hospital distances.

The study modelled four MCR procedures separately in an individual model in accordance with the German policy context: complex oesophageal interventions, complex pancreatic interventions, stem cell transplantation, and total knee replacement. The spatial model for Germany involved three steps: (1) delimiting cooperating hospitals, (2) iterative grouping, and (3) categorising hospital groups.

The grouping process described above resulted in 55 (oesophagus), 126 (pancreas), 39 (stem cell), and 672 (knee) groups across Germany. A total of 50.9%, 49.2%, 51.3%, and 81.5% respectively of these groups contained only one hospital (no cooperation needed). 7, 28, 2, and 22 groups require joint MCR compliance, whereas 19, 21, 8, and 8 hospitals are recommended special permission with a reduced caseload threshold to ensure spatial accessibility for certain regions. The results inform regional policy makers based on the hospital decision space.

This study models potential hospital cooperation based on proximity and caseload, introducing joint MCR compliance. The modelling process supports the formation, categorisation, and analysis of hospital groups, with parameter thresholds enabling flexible policy testing. This approach considers hospitals’ intentions and motivations regarding MCRs, and reserves their decision space. This spatial model provides a theoretical basis for granting exceptional MCR permissions to improve spatial accessibility.

The online version contains supplementary material available at 10.1186/s12942-025-00442-6.