The SAGES Manual of Quality Outcomes and Patient Safety 2nd Edition John R Romanelli Jonathan M Dort Rebecca B Kowalski Prashant Sinha
The SAGES Manual of Quality Outcomes and Patient Safety 2nd Edition John R Romanelli Jonathan M Dort Rebecca B Kowalski Prashant Sinha
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Editors
John R. Romanelli, Jonathan M. Dort, Rebecca B. Kowalski and
Prashant Sinha
Jonathan M. Dort
Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA,
USA
Rebecca B. Kowalski
Department of Surgery, Lenox Hill Hospital, New York, NY, USA
Prashant Sinha
Department of Surgery, NYU Langone Medical Center, Brooklyn, NY, USA
© SAGES 2022
This work is subject to copyright. All rights are solely and exclusively
licensed by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in
any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
Thomas A. Aloia
University of Texas MD Anderson Cancer Center, Houston, TX, USA
Adnan Alseidi
Department of Surgery, University of California San Francisco, San
Francisco, CA, USA
Sharon Bachman
Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA,
USA
Limaris Barrios
Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD), Nova
Southeastern University in Florida, Fort Lauderdale, FL, USA
Marylise Boutros
Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish
General Hospital, Montreal, QC, Canada
L. Michael Brunt
Department of Surgery and Section of Minimally Invasive Surgery,
Washington University School of Medicine, St. Louis, MO, USA
Stephanie Calcasola
Hartford HealthCare, Hartford, CT, USA
Nabajit Choudhury
The University of Tennessee Health Science Center, Memphis, TN, USA
Freeman Condon
Tripler Army Medical Center, Honolulu, HI, USA
Tiffany C. Cox
Department of Surgery, Uniformed Services University of Health
Sciences & Walter Reed National Military Medical Center, Bethesda, MD,
USA
M. Shane Dawson
Northwell Health at Lenox Hill Hospital, New York, NY, USA
Peter M. Denk
GI Surgical Specialists, Fort Myers, FL, USA
Diana L. Diesen
Department of Surgery, University of Texas Southwestern Medical
Center, Dallas, TX, USA
Justin B. Dimick
Department of Surgery, University of Michigan, Ann Arbor, MI, USA
Jonathan M. Dort
Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA,
USA
Christopher G. DuCoin
Department of Surgery, University of South Florida Morsani College of
Medicine, Tampa, FL, USA
Shaina R. Eckhouse
Section of Minimally Invasive Surgery, Department of Surgery,
Washington University School of Medicine, Saint Louis, MO, USA
Yasmin Essaji
Division of HPB Surgery, Virginia Mason Medical Center, Seattle, WA,
USA
Liane S. Feldman
Department of Surgery, McGill University, Montreal, QC, Canada
Julio F. Fiore
Department of Surgery, McGill University, Montreal, QC, Canada
Benjamin J. Flink
Stony Brook University Department of Surgery, Division of Bariatric,
Foregut, and Advanced Gastrointestinal Surgery, Stony Brook, NY, USA
Timothy Fokken
Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA,
USA
Teresa Fraker
Metabolic and Bariatric Surgery Accreditation and Quality
Improvement Program (MBSAQIP), Division of Research and Optimal
Patient Care (DROPC), American College of Surgeons (ACS), Chicago, IL,
USA
Gerald M. Fried
Professor of Surgery and Associate Dean for Education Technology and
Innovation, Montreal, QC, Canada
Faculty of Medicine and Health Sciences, McGill University, Montreal,
QC, Canada
Director, Steinberg Centre for Simulation and Interactive Learning,
Faculty of Medicine and Health Sciences, McGill University, Montreal,
QC, Canada
Pascal Fuchshuber
Sutter East Bay Medical Group, UCSF-East Bay, Oakland, CA, USA
Rebecca Gates
Virginia Tech Carilion School of Medicine and Carilion Clinic, Roanoke,
VA, USA
Kim Gerling
Department of Surgery, Uniformed Services University of Health
Sciences & Walter Reed National Military Medical Center, Bethesda, MD,
USA
Michael Ghio
Tulane University School of Medicine & Tulane Medical Center, New
Orleans, LA, USA
William Greif
The Permanente Medical Group, Kaiser Walnut Creek Medical Center,
Walnut Creek, CA, USA
Anjali A. Gresens
Bariatric Surgery, Sentara Medical Group, Norfolk, VA, USA
Department of Surgery, Eastern Virginia Medical School, Norfolk, VA,
USA
Rana M. Higgins
Medical College of Wisconsin, Milwaukee, WI, USA
Ryan Howard
Department of Surgery, University of Michigan, Ann Arbor, MI, USA
Eunice Y. Huang
Departments of General and Thoracic Surgery, Monroe Carell Jr.
Children’s Hospital at Vanderbilt, Nashville, TN, USA
Daniel B. Jones
Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ,
USA
Carolyn Judge
Department of Surgery, Uniformed Services University of Health
Sciences & Walter Reed National Military Medical Center, Bethesda, MD,
USA
Michael R. Keating
University of Texas Southwestern, Dallas, TX, USA
Deborah S. Keller
Division of Colorectal Surgery, Department of Surgery, University of
California at Davis, Sacramento, CA, USA
Leena Khaitan
University Hospitals, Department of Surgery, Cleveland, OH, USA
James R. Korndorffer Jr
Department of Surgery, Stanford University School of Medicine,
Stanford, CA, USA
Anai N. Kothari
Department of Surgery, Division of Surgical Oncology, Medical College
of Wisconsin, Milwaukee, WI, USA
Rebecca B. Kowalski
Northwell Health at Lenox Hill Hospital, New York, NY, USA
Danuel Laan
Tulane University School of Medicine & Tulane Medical Center, New
Orleans, LA, USA
Kathleen Lak
Bariatric and Minimally Invasive Gastrointestinal Surgery, Medical
College of Wisconsin, Milwaukee, WI, USA
Teresa L. LaMasters
Iowa Methodist Medical Center Unity Point Clinic, University of Iowa,
Des Moines, IA, USA
James N. Lau
Loyola University Medical Center, Department of Surgery, Maywood, IL,
USA
Shauna Levy
Tulane University School of Medicine & Tulane Medical Center, New
Orleans, LA, USA
Anne O. Lidor
Department of Surgery, Johns Hopkins University SOM, Baltimore, MD,
USA
Cara A. Liebert
Department of Surgery, Stanford University School of Medicine, VA Palo
Alto Health Care System, Palo Alto, CA, USA
Robert Lim
University of Oklahoma School of Medicine Tulsa, Tulsa, OK, USA
Jamie P. Loggins
Mission Weight Management Center, Asheville, NC, USA
Matthew Madion
Medical College of Wisconsin, Milwaukee, WI, USA
Kelly Mahuron
Department of Surgery, University of California San Francisco, San
Francisco, CA, USA
John D. Mellinger
Southern Illinois University School of Medicine, Department of Surgery,
Springfield, IL, USA
Samuel M. Miller
Department of Surgery, Yale School of Medicine, New Haven, CT, USA
Jeongyoon Moon
Division of Colon and Rectal Surgery, Sir Mortimer B. Davis Jewish
General Hospital, Montreal, QC, Canada
Lee Morris
Department of Surgery, The Houston Methodist Hospital, Houston, TX,
USA
John M. Morton
Department of Surgery, Yale School of Medicine, New Haven, CT, USA
Madhuri B. Nagaraj
University of Texas Southwestern, Department of Surgery, Dallas, TX,
USA
Brian J. Nasca
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Ugoeze J. Nwokedi
Department of Surgery, The Houston Methodist Hospital, Houston, TX,
USA
Jaisa Olasky
Mount Auburn Hospital, Harvard Medical School, Boston, MA, USA
Charles Paget
Virginia Tech Carilion School of Medicine and Carilion Clinic, Roanoke,
VA, USA
John T. Paige
Department of Surgery, MedicineLouisiana State University (LSU)
Health New Orleans School of Medicine, New Orleans, LA, USA
V. Prasad Poola
Southern Illinois University School of Medicine, Department of Surgery,
Springfield, IL, USA
Aurora D. Pryor
Stony Brook University Department of Surgery, Division of Bariatric,
Foregut, and Advanced Gastrointestinal Surgery, Stony Brook, NY, USA
Fateme Rajabiyazdi
Department of Systems and Computer Engineering, Carleton University,
Ottawa, ON, Canada
Bruce Ramshaw
Managing Partner, CQInsights PBC, Knoxville, TN, USA
Stacy M. Ranson
Inova Fairfax Medical Campus, Falls Church, VA, USA
Arthur Rawlings
General Surgery, University of Missouri, One Hospital Drive, Columbia,
MO, USA
Swathi Reddy
Johns Hopkins University School of Medicine, Baltimore, MD, USA
Adam Reid
Southern Illinois University School of Medicine, Department of Surgery,
Springfield, IL, USA
Caroline E. Reinke
Department of Surgery, Atrium Health, Charlotte, NC, USA
Amelia T. Collings
Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
John R. Romanelli
Department of Surgery, University of Massachusetts Chan Medical
School - Baystate Medical Center, Springfield, MA, USA
Ingrid S. Schmiederer
Department of Surgery, Stanford University School of Medicine,
Stanford, CA, USA
New York Presbyterian-Queens, Department of Surgery, Flushing, NY,
USA
Benjamin E. Schneider
University of Texas Southwestern, Dallas, TX, USA
Erin Schwarz
SAGES, Los Angeles, CA, USA
Daniel J. Scott
University of Texas Southwestern, Department of Surgery and
Simulation Center, Dallas, TX, USA
Marinda Scrushy
Department of Surgery, University of Texas Southwestern Medical
Center, Dallas, TX, USA
Neal E. Seymour
Baystate Medical Center, Department of Surgery, Springfield, MA, USA
Phillip P. Shadduck
Duke University, Durham, NC, USA
Prashant Sinha
Department of Surgery, NYU Langone Medical Center, Brooklyn, NY, USA
Brandon W. Smith
Baystate Medical Center, Department of Surgery, Springfield, MA, USA
Eileen R. Smith
Section of Minimally Invasive Surgery, Department of Surgery,
Washington University School of Medicine, Saint Louis, MO, USA
Dimitrios Stefanidis
Department of Surgery, Indiana University School of Medicine,
Indianapolis, IN, USA
Jonah J. Stulberg
The University of Texas Health Science Center at Houston, Houston, TX,
USA
Joseph A. Sujka
Department of Surgery, University of South Florida Morsani College of
Medicine, Tampa, FL, USA
Dina Tabello
Inova Fairfax Medical Campus, Falls Church, VA, USA
Nabil Tariq
Department of Surgery, The Houston Methodist Hospital, Houston, TX,
USA
Jacob A. Tatum
Department of Surgery, Eastern Virginia Medical School, Norfolk, VA,
USA
Dana A. Telem
National Clinician Scholars Program, University of Michigan, Ann Arbor,
MI, USA
Shawn Tsuda
Valley Health System General Surgery Department, Las Vegas, NV, USA
Buğra Tugertimur
General Surgery Resident, PGY 5, Department of Surgery, Lenox Hill
Hospital, Northwell Health, New York City, NY, USA
Sofia Valanci
Doctoral student in Experimental Surgery, Education Concentration,
McGill University, Montreal, QC, Canada
Valeria S. M. Valbuena
University of Michigan, Department of Surgery, Ann Arbor, MI, USA
Sherry M. Wren
Department of Surgery, Center for Innovation and Global Health,
Stanford University School of Medicine, VA Palo Alto Health Care
System, Palo Alto, CA, USA
Tonia M. Young-Fadok
Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, AZ, USA
Joseph Youssef
University Hospitals, Department of Surgery, Cleveland, OH, USA
Brenda M. Zosa
Department of Surgery, Johns Hopkins University SOM, Baltimore, MD,
USA
Part I
Surgical Quality
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
J. R. Romanelli et al. (eds.), The SAGES Manual of Quality, Outcomes and Patient Safety
https://doi.org/10.1007/978-3-030-94610-4_1
Justin B. Dimick
Email: [email protected]
Introduction
With recognition of wide variations in surgical performance, demand
for information on surgical quality is at an all-time high. Patients and
families are turning to their physicians, hospital report cards, and the
Internet to identify the safest hospitals for surgery [1]. Payers and
purchasers are using efforts to reward high quality (e.g., pay for
performance) or steer patients toward the highest quality providers
(e.g., selective referral) [2]. In addition to responding to these external
demands, providers are becoming more involved in leveraging their
own quality measurement platforms to improve surgical care, such as
the National Surgical Quality Improvement Program (NSQIP) [3].
Finally, professional organizations are now accrediting hospitals based
on their ability to meet certain metrics believed to be associated with
better outcomes [4].
Despite the need for good measures of quality in surgery, there is
very little agreement about how to best assess surgical performance.
According to the widely used Donabedian paradigm, quality can be
measured using various aspects of structure, process, or outcome [5].
In addition, many widely recognized quality measurement efforts, such
as those by the Leapfrog group, use composite, or “global,” measures of
quality, which combine one or more elements of structure, process, and
outcome [6]. In this chapter, we consider the advantages and
disadvantages of each type of quality measure. We close by making
recommendations for choosing among these different approaches.
Structure
The structure of surgical care refers to measurable attributes of a
hospital (e.g., size and volume) or its providers (e.g., specialty training
and years in practice) (Table 1.1). Measures of structure are extensively
used in the measurement of surgical quality, owing to their widespread
availability. The American College of Surgeons (ACS) and the American
Society of Metabolic and Bariatric Surgeons (ASMBS) accredit hospitals
for bariatric surgery based largely on measures of structure, including
hospital volume, surgeon volume, and other structural elements
necessary for providing multidisciplinary care for the morbidly obese
[4].
Table 1.1 Approaches to measuring the quality of care for aortic surgery with
advantages and disadvantages of each approach
Process
Processes of care are the steps and details of a patient’s care that can
lead to good (or bad) outcomes. Although processes of care can
represent details of care in the preoperative, intraoperative, and
postoperative phases, the most familiar process measures focus on
details in the immediate preoperative phase of patient care. For
example, the Center for Medicare and Medicaid Services (CMS) Surgical
Care Improvement Project (SCIP) measures utilization of preoperative
antibiotic and venous thromboembolism prophylaxes. Along these
lines, one of the most familiar approaches to improving the process of
care in surgery is the use of a presurgical checklist, which verifies that a
number of best practices (confirming patient name, procedure
laterality, administration of antibiotics, etc.) have been performed [12].
This has now become standard practice in the United States.
Process measures have several strengths as quality measures (Table
1.1). First, processes of care are extremely actionable in quality
improvement. When hospitals and surgeon are “low outliers” for
process compliance (e.g., patients not getting timely antibiotic
prophylaxis), they know exactly where to target improvement. Second,
in contrast to risk-adjusted outcomes measurement, processes of care
do not need to be adjusted for differences in patient risk, which limits
the need for data collection from the medical chart and saves valuable
time and effort.
However, using processes of care has several significant limitations
in surgery. First, most existing process measures are not strongly
related to important outcomes. For example, the SCIP measures, which
are by far the most widely used process measure in surgery, are not
related to surgical mortality, infections, or thromboembolism [13].
Similarly, after implementing the preoperative checklist in 101
hospitals in Ontario, Canada, there was no measurable change in
postoperative complications or mortality [14]. The lack of a
relationship between process improvement and surgical mortality can
be explained by the fact that the complications they aim to prevent are
secondary (e.g., superficial wound infection) or extremely rare (e.g.,
pulmonary embolism). However, there is also a very weak relationship
between process measures and the outcome they are supposed to
prevent (e.g., timely administration of prophylactic antibiotics and
wound infection) [15]. This finding is more difficult to explain. It is
possible that there are simply multiple other processes (many
unmeasured or unmeasurable) that contribute to good surgical
outcomes. As a result, it is likely that adherence to process best
practices is necessary but not sufficient for good surgical outcomes.
Outcome
Outcomes represent the end results of care. In surgery, the most
commonly evaluated outcomes are mortality, serious complications,
and hospital readmissions. For example, the NSQIP, the largest clinical
registry focusing on surgery, reports risk-adjusted morbidity and
mortality rates to participating hospitals [3]. While morbidity and
mortality have long been the “gold standard” in surgery, patient-
reported outcomes such as functional status and quality of life are also
critically important.
Direct outcome measures have several strengths (Table 1.1). First,
everyone agrees that outcomes are important. Measuring the end
results of care makes intuitive sense to surgeons and other
stakeholders. For example, the NSQIP has been enthusiastically
championed by surgeons and other clinical leaders [16]. Second,
outcomes feedback alone may improve quality. This so-called
Hawthorne effect is seen whenever outcomes are measured and
reported back to providers. For example, the NSQIP in the Veterans
Affairs (VA) hospitals and private sector has documented
improvements over time that cannot be attributed to any specific
efforts to improve outcomes [17].
However, outcome measures have key limitations. First, when the
event rate is low (numerator) or the number of cases is small
(denominator), outcomes cannot be reliably measured. Small sample
size and low event rates conspire to limit the statistical power of
hospital outcomes comparisons. For most operations, surgical
mortality is too rare to be used as a reliable quality measure [18]. For
example, a study examining seven operations for which mortality was
advocated as a quality measure by the Agency for Healthcare Research
and Quality (AHRQ) found that only one of the seven operations –
coronary artery bypass surgery – had high enough caseloads to reliably
measure quality with surgical mortality [19].
Accurately measuring and comparing outcomes as a quality
improvement instrument is also confounded by many factors. Surgical
outcomes are influenced not only by quality of care but also by random
variation, sample size, and case mix. Whereas structure and process
measure are fixed elements of care, outcomes require additional risk
and reliability adjustment to account for these confounders [20].
Acquiring the data necessary to make these adjustments is labor-
intensive and expensive. For example, the NSQIP collects more than 80
patient variables from the medical chart for this purpose [17]. Each
NSQIP hospital employs a trained nurse clinician to collect this data.
Composite
Composite measures are created by combining one or more structure,
process, and outcome measures [21]. Composite measures offer several
advantages over the individual measures discussed above (Table 1.1).
By combining multiple measures, it is possible to overcome problems
with small sample size discussed above. Composite measures also
provide a “global” measure of quality. This type of measure has been
used for quality for value-based purchasing or other efforts that require
an overall or summary measure of quality.
One key limitation with composite measures is that there is no “gold
standard” approach for weighting input measures. Perhaps the most
common approach is to weight each input measure equally. For
example, in the ongoing Premier/CMS pay for performance initiative,
individual measures are weighted. However, this approach is also
flawed insofar as variation in these composite measures is entirely
driven by the process measures [22].
Another limitation with composite measures is that they are not
always actionable for quality improvement. By combining information
on multiple measures and/or clinical conditions, there is often not
enough “granularity” for clinicians to use the information for quality
improvement. To target quality improvement efforts, it is often
necessary to deconstruct the composite into its component measures
and find out where the problem lies (e.g., the specific procedure or
complication).
Patient-Reported Outcomes
An important element of surgical quality not captured in the traditional
Donabedian paradigm outlined above is patient-reported outcomes.
There is now wide recognition of the importance of patient-reported
outcomes. These outcomes capture the patient’s perspective on their
postoperative experience, and common measures include functional
status, satisfaction, and quality of life.
CMS now uses the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) survey as part of its value-based
purchasing program. Although it is still unclear how these outcomes
can be meaningfully integrated into actionable quality improvement
efforts, they are nevertheless a necessary complement to traditional
outcome measures [23]. It has been demonstrated that there is a high
association between patient satisfaction and traditional objective
outcome measures [24]. This suggests that efforts and policies to
improve the patient experience can be undertaken without negatively
impacting other important outcome measures.
Figure 1.1 Choosing among measures of structure, process, and outcomes. For high-
risk, high caseload operations (e.g., colectomy and bariatric procedures), outcomes
are useful quality measures. For low-risk, common procedures (e.g., inguinal hernia
repair), processes of care or functional outcomes are appropriate measures. For high-
risk, uncommon operations (e.g., gastric and pancreatic cancer resection), measures
of structure, such as hospital volume, are most appropriate. For low-risk, low
caseload operations (e.g., spigelian hernia repair), it would be best to focus
measurement efforts elsewhere. (Figure modified by Birkmeyer et al. [5])
When choosing an approach to quality measurement, the specific
policy application should also be considered. In particular, it is
important to distinguish between policy efforts aimed at selective
referral and quality improvement. For selective referral, the main goal
is to redirect patients to the highest quality providers. Structural
measures, such as hospital volume, are particularly good for this
purpose. Hospital volume tends to be strongly related to outcomes, and
large gains in outcomes could be achieved by concentrating patients in
high-volume hospitals. In contrast, structural measures are not directly
actionable and, therefore, do not make good measures for quality
improvement. For improving quality, process and outcome measures
are better because they provide actionable targets. Surgeons and
hospitals can improve by addressing problems with process
compliance or focus on clinical areas with high rates of adverse
outcomes. For example, the NSQIP reports risk-adjusted morbidity and
mortality rates to every hospital. Surgeon champions and quality
improvement personnel will target improvement efforts to areas where
performance is statistically worse than expected.
Conclusions
Each type of quality measure – structure, process, and outcome – has its
unique strengths and limitations. Structural measures are strongly
related to outcomes but do not discriminate among individual
providers. Process measures offer actionable steps for improvement
but often have a tenuous association with outcomes. Outcomes are the
bottom line in surgery, but sampling and adjustment methods are
needed to meaningfully compare them between hospitals and surgeons.
Other measures such as patient-reported outcomes offer critical
information, but their incorporation into quality improvement efforts is
less clear. Ultimately, when choosing among the various approaches to
define surgical quality, surgeons need to be flexible and consider the
specific policy application prior to selecting a single measure.
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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
J. R. Romanelli et al. (eds.), The SAGES Manual of Quality, Outcomes and Patient Safety
https://doi.org/10.1007/978-3-030-94610-4_2
Jacob A. Tatum
Email: [email protected]
Introduction
“Never events” were first introduced in 2001 by Dr. Ken Kizer, former
CEO of the National Quality Forum (NQF) organization that promotes
patient safety and quality healthcare [1]. The term refers to medical
errors and events that are so egregious that they should be avoidable,
preventable, and never occur, such as wrong-site surgery or surgery
performed on the wrong patient [2]. Though these might seem
shocking, serious preventable surgical errors occur every year despite
considerable patient safety initiatives. Overall, medical errors are
suspected to contribute to over 251,000 deaths per year in the United
States, with an estimated 4000 surgical never events occurring yearly
[3]. Globally, Haynes et al. estimate a rate of serious incidents occurring
in 1/10,000 patients, with up to one million deaths per year [4, 5].
While an individual hospital may only see a wrong-site surgery every
5–10 years, other serious errors may occur more frequently causing
undue harm to many patients. From 2007 to 2019, 71% of never events
reported to the Joint Commission resulted in fatality [1].
Medical errors and adverse events in healthcare impose a costly toll
not only on the patient involved but also to the providers and the
institution. The burden is mental as well as financial and can be
devastating. In 2011, data from the NQF estimated that serious
reportable errors lead to $5.7 billion in additional healthcare costs.
When including healthcare expenses, lost productivity, lost income, and
disability, costs may exceed $29 billion per year in the United States [6].
Table 2.1 National Quality Forum serious reportable events/never events [8]
Surgical events
Surgery or other invasive procedure performed on the wrong site
Surgery or other invasive procedure performed on the wrong patient
Wrong surgical or other invasive procedure performed on a patient
Unintended retention of a foreign object in a patient after surgery or other invasive
procedure
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abgestattet haben, scheiden wir von Trier, wo so herrlicher Wein uns
labte, um auch anderen schönen Punkten im Moseltal einen
flüchtigen Wandergruß zu bringen.
Es fehlt der Raum, um das Moseltal, das so
viele herrliche Schönheiten entfaltet, in gleicher Das Moseltal.
Ausführlichkeit wie das Rheintal zu behandeln. Wir
müssen uns darauf beschränken, die Eigenart dieses größten
Nebentales gegenüber dem Haupt-, dem Rheintale, zu zeigen und
zu begründen. Übereinstimmend ist der reiche Rebenschmuck der
Bergwände, die ebenfalls aus schiefrigem Gestein bestehen; gleich
ist auch die große Zahl der Burgen, die malerisch die Berge krönen;
sehr ähnlich ferner das Bild der Ortschaften, die an den Fluß sich
betten, und deren schiefergraue Dächer im Sonnenschein hell
aufblitzen. Und doch wie verschieden ist das Gesamtbild! Weniger
großartig ist das Moseltal, wie auch sein Fluß sich mit dem stolzen
Rheinstrom nicht messen kann. Aber ein reicherer Wechsel des
landschaftlichen Bildes ist ihm eigen. Schon die viel zahlreicheren
Biegungen, die die Mosel macht, bewirken dies; denn bei jeder
Biegung öffnet sich dem Auge ein neues, oft völlig anderes Bild,
während sich im Rheintal jeder Blick ins Endlose verlängert. Am
wenigsten ist die unterste Strecke des rheinischen Mosellaufs, von
Cochem ab, durch Biegungen gegliedert, am reichsten das mittlere
Drittel zwischen Bernkastel und Cochem. Dort macht der Fluß
vielstundenlange Umwege, um fast zur nämlichen Stelle
zurückzukehren. Am meisten nähert er sich selbst wieder nach der
großen Schleife von Zell an der Stelle, wo die auf hohem Felskamm
gelegene Marienburg (Abb. 100) zur Betrachtung des eigenartigen
Landschaftsbildes mit einem doppelten Flußlaufe einladet.
Abb. 114. Die Apollinariskirche in Remagen. (Zu Seite 117.)
Unter den Moselorten sind manche, die auf ein hohes Alter
zurückschauen können, wie Pfalzel (von Palatiolum), wo Adela, die
Tochter des Frankenkönigs Dagobert II., ein Frauenkloster gründete;
Riol (von Rigodulum), wo nach dem Bericht des Tacitus der römische
Feldherr Cerealis die Treverer besiegte; Neumagen (von
Noviomagus), wo in der Nähe der Kirche eine Festung Constantins
lag, die der Dichter Ausonius erwähnt: