All Patient Refined Diagnosis Related Groups Severity Research Articles

Creation and Validation of a Stroke Scale to Increase Utility of National Inpatient Sample Administrative Data for Clinical Stroke Research

IntroductionThe National Inpatient Sample (NIS) has led to several breakthroughs via large sample size. However, utility of NIS is limited by the lack of admission NIHSS and 90-day modified Rankin score (mRS). This study creates estimates for stroke severity at admission and 90-day mRS using NIS data for acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). MethodsThree patient cohorts undergoing MT for AIS were utilized: Cohort 1 (N = 3729) and Cohort 3 (N = 1642) were derived from NIS data. Cohort 2 (N=293) was derived from a prospectively-maintained clinical registry. Using Cohort 1, Administrative Stroke Outcome Variable (ASOV) was created using disposition and mortality. Factors reflective of stroke severity were entered into a stepwise logistic regression predicting poor ASOV. Odds ratios were used to create the Administrative Data Stroke Scale (ADSS). Performances of ADSS and ASOV were tested using Cohort 2 and compared with admission NIHSS and 90-day mRS, respectively. ADSS performance was compared with All Patient Refined-Diagnosis Related Group (APR-DRG) severity score using Cohort 3. ResultsAgreement of ASOV with 90-day mRS > 2 was fair (κ = 0.473). Agreement with 90-day mRS > 3 was substantial (κ = 0.687). ADSS significantly correlated (p < 0.001) with clinically-significant admission NIHSS > 15. ADSS performed comparably (AUC = 0.749) to admission NIHSS (AUC = 0.697) in predicting 90-day mRS > 2 and mRS > 3 (AUC = 0.767, 0.685, respectively). ADSS outperformed APR-DRG severity score in predicting poor ASOV (AUC = 0.698, 0.682, respectively). ConclusionWe developed and validated measures of stroke severity at admission (ADSS) and outcome (ASOV, estimate for 90-day mRS > 3) to increase utility of NIS data in stroke research.

Author response: Readmission to a different hospital following acute stroke is associated with worse outcomes.

We would like to thank Chen et al.1 for their interest in our study. We agree that it is important to consider stroke severity and the possibility that quality of care was suboptimal during the index admission. Indeed, we specifically designed our analyses to minimize the likelihood that readmissions were related to higher stroke severity or to unsatisfactory treatment at the first hospital. Although the Nationwide Readmissions Database does not include data on stroke severity, we used the All Patient Refined Diagnosis Related Groups (APRDRG) severity of illness and risk of mortality measures as a measure of overall illness severity. Our fully adjusted models account for both APRDRG severity and mortality. To minimize the likelihood that unsatisfactory treatment at the first hospital contributed to readmission, we excluded patients transferred to a higher level of care during index hospitalization. Finally, Table 2 reports the length of hospital stay and total charges of hospitalization during the index admission. In addition to demographics, vascular risk factors, insurance, discharge disposition, and APRDRG severity or mortality, our fully adjusted model also included adjustment for hospital characteristics, length of stay, and total charges during the index hospitalization.

Use of Intravenous Immunoglobulin G in HIT: Impact on Thrombosis and Mortality in a Population-Based Study

Introduction: Heparin-induced thrombocytopenia (HIT) is a severe prothrombotic syndrome with a mortality rate of 10% (Lancet Haematol. 2018 May; 5(5):e220-e231). Case reports show that Intravenous Immunoglobulin G (IVIg) can rapidly and durably counteract HIT antibody-mediated platelet activation in the setting of severe persistent HIT (Chest. 2017 Sep;152(3):478-485 and others). While this data supports use of IVIg in severe HIT, it is well documented that “positive result bias” enhances the likelihood of publication of studies that demonstrate salutary effects of interventions. IVIg has a black box warning for thrombosis which lists a number of potential predisposing states for this complication including hypercoagulable conditions (such as HIT). Thus, one concern is that of new/worsening thrombosis in HIT patients treated with this drug, something that is not evaluable with the limited publications in this area. The Nationwide Inpatient Sample (NIS) is the largest publicly available patient discharge database in the US that includes ~7 million discharges per year representative of discharges from all hospital types in the country. The goal of this study was to evaluate thrombosis, bleeding and mortality outcomes associated with IVIg use in HIT using the NIS database.Methods: Hospital discharges with an ICD-9-CM code for HIT (289.84) in the NIS were used to compare outcomes in adult patients (≥18yrs) who did and did not receive IVIg treatment (ICD-9-CM code 99.14) from October 1, 2008 to December 31, 2014. Discharges with diagnoses suggestive of a history of thrombosis (ICD-9-CM codes V12.51, V12.52, V12.55), idiopathic thrombocytopenic purpura (287.31), or secondary thrombocytopenia (287.4) were excluded. Patient characteristics included age, sex, all patient refined diagnosis related groups (APR-DRG) severity index, and APR-DRG mortality index. Outcomes included arterial thrombosis, venous thrombosis, bleeding, mortality, and a composite of all outcomes. Variables were compared by IVIg treatment status using survey weighted Chi-squared tests for categorical variables and ANOVA for continuous variables. Survey weighted multiple logistic regression was used to model each binary outcome by IVIg treatment status while adjusting for age, gender, APR-DRG severity index and mortality index. A matched analysis was performed as a sensitivity analysis for the multiple logistic regression results. Controls were matched with IVIg cases by exact gender, APRDRG severity index, and mortality index. Five matching controls were selected for each case based on nearest age. Conditional logistic regression was used to analyze each outcome using the matched dataset.Results: HIT patients treated with IVIg and those without were no different in age and sex (Table 1). Consistent with the limited published experience of IVIg use in HIT, those who received IVIg had more severe disease with greater likelihood of dying as indicated by their APR-DRG severity and mortality indices (Table 1). Multiple logistic regression showed that the adjusted odds ratio (aOR) was lower for all outcomes except bleeding in the IVIg-treated group, although this did not reach statistical significance (Fig 1; aOR of 0.766, 0.922, 1.049, 0.685 and 0.703 for arterial thrombosis, venous thrombosis, bleeding, death and composite outcome, respectively). Similar results were obtained in conditional logistic regression of matched data (Fig 2).Conclusions: Use of IVIg was not associated with worse thrombotic outcomes or mortality in HIT. On the contrary, results suggest a possible protective effect on these outcomes, but results did not achieve statistical significance possibly due to small numbers of IVIg-treated patients. The aOR was higher (but not significantly so) for bleeding in IVIg-treated HIT patients, however, this finding is consistent with the possibility that IVIg was used more frequently in patients who had more severe disease (and had already hemorrhaged), as suggested by worse APR-DRG severity and mortality indices in IVIg-treated patients. A prospective randomized treatment study may be necessary to provide conclusive data on IVIg efficacy and risk in HIT. [Display omitted] DisclosuresDhakal:Amgen: Honoraria; Celgene: Consultancy, Honoraria; Takeda: Honoraria. Aster:BloodCenter of Wisconsin: Patents & Royalties. Padmanabhan:Janssen Pharmaceuticals: Consultancy; GE Healthcare: Other: Material support for Clinical Quality Improvement Initiative; Retham Technologies LLC: Equity Ownership, Other: Retham seeks to develop HITDx(TM), a new assay for HIT diagnosis; BloodCenter of Wisconsin: Patents & Royalties: Patent/royalties for HIT diagnostic testing; Veralox Therapeutics: Other: Advisory Board; TerumoBCT: Consultancy.

Cost Savings from Reducing Pain Through the Delivery of Integrative Medicine Program to Hospitalized Patients.

An important task facing hospitals is improving pain management without raising costs. Integrative medicine (IM), a promising nonpharmacologic pain management strategy, is yet to be examined for its cost implications in an inpatient setting. This institution has had an inpatient IM department for over a decade. The purpose was to examine the relationship between changes in patients' pain, as a result of receiving IM therapy, and total cost of care during an inpatient hospital admission. In this retrospective analysis, data from an EPIC-based electronic health record (EHR) patient demographics, length of stay (LOS), and All Patient Refined Diagnosis Related Groups (APR-DRG) severity of illness measures were utilized. IM practitioners collected and entered patient-reported pain scores into the EHR. The authors regressed the demographic, change in pain, LOS, and APR-DRG variables with changes in pain on total cost for the hospital admission. To estimate cost savings to the hospital, they computed the average reduction in cost associated with reduction in pain by multiplying the coefficient for change in pain by average total cost. A large, tertiary care hospital in Minneapolis, MN. Adult inpatient admissions, 2730, during the study period where patients received IM for pain and met eligibility criteria. IM services provided to inpatients. Change in pain on an 11-point numeric rating scale before and after initial IM sessions; total costs for hospital admissions. Both LOS and age were found to increase cost, as did being white, male, married, and having APR-DRG severity coded as extreme. For patients receiving IM therapies, pain was reduced by an average of 2.05 points and this pain reduction was associated with a cost savings of $898 per hospital admission. For patients receiving IM therapies, pain was significantly reduced and costs were lowered by about 4%.

Abstract WMP33: Real-World Clinical Outcomes of Ruptured Intracranial Arterial Aneurysm Treatment

Introduction: Comparison of real world clinical outcomes between clipping and coiling for ruptured aneurysm is challenging, mainly due to confounding case severity and variation in physician expertise. We sought to compare outcomes and costs of coiling and clipping by utilizing a large national database. Methods: Ruptured intracranial aneurysm patients age 18 to 86 years were identified from the National Inpatient Sample (NIS) from 2007 to 2013. The clinical outcomes evaluated were in-hospital mortality, in-hospital stroke, discharge destination and other complications. Also, the total hospitalization cost was compared. Multivariate logistic regression and propensity-score matching were used. Confounding factors such as specific neurovascular comorbidities (e.g. hypertension, diabetes), Charleson comorbidity index (CCI), all patient refined diagnosis related group (APR-DRG) risk of mortality, APR-DRG severity index, and NIS-SAH severity score were also controlled for. Results: 14379 patients with ruptured intracranial arterial aneurysms were identified (5966 clipping, 8413 coiling). Univariate analysis showed that coiling patients had higher preprocedural risks by CCI (p &lt; 0.001) and APR-DRG mortality (p&lt;0.001). Multivariate analysis showed no difference in in-house mortality (OR 0.96, p = 0.60), but coiling showed lower in-house strokes (OR 0.67, p &lt; 0.001) and more discharge to a rehabilitation facility (OR 0.63, p&lt;0.001). Coiling patients had higher odds of a hematoma (OR 1.44, p = 0.09) and hydrocephalus requiring treatment (OR 1.55, p&lt;0.01), but lower odds of requiring a blood transfusion (OR 0.52, p&lt;0.01). Analysis over time showed that in-house mortality has decreased over time (p=0.01) in coiling patients, but mortality after clipping has not changed. Coiling was slightly more expensive, but the difference was not significant ($2267, p=0.13). Conclusions: After adjusting for severity, there was no significant difference in mortality between coiling and clipping in ruptured aneurysm treatment. However, coiling patients had a lower chance of an in-hospital stroke and a higher chance of being discharged home. A limitation of the study is the possibility of unmeasured confounders.

Abstract TP192: Epidemiological Characteristics and Outcomes of Takayasu’s Arteritis in Acute Ischemic Stroke Hospitalization

Background: Takayasu’s arteritis (TA) is an uncommon disease, characterized by granulomatous vasculitis of medium and large arteries especially aorta and its branches. The incidence of TA is calculated to be 0.26-case/100,000/ year in the USA. Neurological involvement is reported in only a minority of patients and occurrence of neurological syndromes as the first manifestation of the disease has been rarely reported. We are describing epidemiological characteristics of a rare disease. Methods: We performed a retrospective cohort analysis of the Nationwide Inpatient Sample (NIS) (years 2000-2011) in adult hospitalizations for AIS to compare the outcomes [Death, All Patient Refined Diagnosis Related Groups (APRDRGs) Risk Mortality (likelihood of dying), Discharge Disposition, APRDRG severity (loss of function)] of patients with TA using ICD-9-CM codes. The APRDRGs are assigned using software developed by 3M Health Information Systems. We also compared their epidemiological characteristics like age, race, gender, preexisting comorbidities, length of stay, and expenditure for treatment. We performed weighted analysis using chi-square and t-test. Results: Among 5,223,800 AIS hospitalizations, 274 were diagnosed with TA. Analysis revealed most TA patients were female (90.7%) and younger in age (Mean: 50.3 years), in compare to non-TA. It was more common in white population. With high likelihood of dying, TA cohort had higher percentage of major loss of function in compare to non-TA. AIS with TA were having longer length of stay and higher cost of treatment (Table). Conclusion: Even though AIS hospitalizations with TA are relatively rare, further research is needed to determine other associations of TA, as it is a burden on healthcare, which has higher association with disability and higher cost.

Differences in severity at admission for heart failure between rural and urban patients: the value of adding laboratory results to administrative data.

BackgroundRural/urban variations in admissions for heart failure may be influenced by severity at hospital presentation and local practice patterns. Laboratory data reflect clinical severity and guide hospital admission decisions and treatment for heart failure, a costly chronic illness and a leading cause of hospitalization among the elderly. Our main objective was to examine the role of laboratory test results in measuring disease severity at the time of admission for inpatients who reside in rural and urban areas.MethodsWe retrospectively analyzed discharge data on 13,998 hospital discharges for heart failure from three states, Hawai’i, Minnesota, and Virginia. Hospital discharge records from 2008 to 2012 were derived from the State Inpatient Databases of the Healthcare Cost and Utilization Project, and were merged with results of laboratory tests performed on the admission day or up to two days before admission. Regression models evaluated the relationship between clinical severity at admission and patient urban/rural residence. Models were estimated with and without use of laboratory data.ResultsPatients residing in rural areas were more likely to have missing laboratory data on admission and less likely to have abnormal or severely abnormal tests. Rural patients were also less likely to be admitted with high levels of severity as measured by the All Patient Refined Diagnosis Related Groups (APR-DRG) severity subclass, derivable from discharge data. Adding laboratory data to discharge data improved model fit. Also, in models without laboratory data, the association between urban compared to rural residence and APR-DRG severity subclass was significant for major and extreme levels of severity (OR 1.22, 95 % CI 1.03–1.43 and 1.55, 95 % CI 1.26–1.92, respectively). After adding laboratory data, this association became non-significant for major severity and was attenuated for extreme severity (OR 1.12, 95 % CI 0.94–1.32 and 1.43, 95 % CI 1.15–1.78, respectively).ConclusionHeart failure patients from rural areas are hospitalized at lower severity levels than their urban counterparts. Laboratory test data provide insight on clinical severity and practice patterns beyond what is available in administrative discharge data.

Analysis of Transurethral Resection of the Prostate Costs across New York State Hospitals Using Severity of Illness Score

IntroductionUsing data on surgical treatment for benign prostatic hyperplasia we evaluated the effect of beneficiary health status on hospital reported costs. MethodsWe examined the records of 9,895 patients in the New York State Hospital Inpatient Cost Transparency database who underwent surgical treatment for benign prostatic hyperplasia, including laser prostatectomy and traditional transurethral resection of the prostate, in New York State from 2009 to 2011. ResultsUsing the 3M™ APR-DRG (All Patient Refined Diagnosis Related Group) severity of illness index as a measure of patient preoperative health we found a significant increase in the cost of transurethral resection of the prostate for patients with higher severity of illness scores. We confirmed an increase in the cost and the cost variability of transurethral resection of the prostate for patients with higher severity of illness scores. ConclusionsOur findings illustrate the inherent unpredictability of cost forecasting and budgeting for these patients.

Effects of Statins on Hospital Length of Stay and All-Cause Readmissions Among Hospitalized Patients With a Primary Diagnosis of Sepsis.

There is little information on the impact of statins on hospital length of stay (LOS) or readmission among patients with sepsis. The objective of this study is to evaluate the association between statin use and LOS and all-cause readmissions among sepsis patients hospitalized in the medical unit. The design was a retrospective propensity score-matched study of adult patients with a primary diagnosis of sepsis from 2007 to 2013. Information was extracted from the electronic health record. Sepsis patients were identified using ICD-9CM codes. Propensity scores estimated the probability that a patient would be on statins, and patients who were on statins were then matched with those who were not, within ±0.05. Additional greedy matching criteria were organ dysfunction (yes/no) and all patient refined diagnosis-related group (APR-DRG) medical/surgical. The primary outcome was LOS, and the secondary outcomes were all-cause readmission at 30, 60, and 90 days, adjusted for age, sex, modified Deyo-Charlson comorbidity index, APR-DRG severity of illness (SOI), and APR-DRG medical/surgical, as appropriate. Patients taking statins had a shorter LOS than patients not taking statins, 8.7 ± 3.7 and 10.3 ± 2.7 days, respectively (P value = 0.018). There was no significant difference (P> 0.05) in all cause readmissions between statin and nonstatin patients. Presence of comorbidities and SOI were significant factors for 60- and 90-day readmissions. The use of statins among patients admitted with primary sepsis in the medical unit was associated with shorter length of hospital stay. However, it did not affect frequency of readmissions.

Healthcare costs and outcomes for pediatric inpatients with bronchiolitis: comparison of urban versus rural hospitals

We conducted a retrospective study to compare the quality and costs of care among rural and urban hospitals for low severity pediatric bronchiolitis admissions. The Agency for Healthcare Research and Quality 2009 Kids’ Inpatient Database provided the data for analysis. Diagnosis and severity of illness levels were based on All Patient Refined Diagnosis-Related Groups (APR-DRG) of 138: bronchiolitis and respiratory syncytial virus pneumonia. We included the lowest severity of illness, as defined by APR-DRG severity classification, comprising 58.8% of all pediatric bronchiolitis discharges. The Institutional Review Boards of Sanford Health and Sanford School of Medicine approved this study (Sanford Health Project Number 03-12-001, meets exempt status; Sanford School of Medicine Project Number 2011.210; meets exempt status).

HCAHPS Survey Results: Impact of Severity of Illness on Hospitals' Performance on HCAHPS Survey Results.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is used by the Centers of Medicare and Medicaid (CMS) to assess inpatient satisfaction. HCAHPS survey results are publicly reported, and performance began to affect CMS reimbursement to hospitals as of FY2013. However, the impact of severity of illness on patients' self-reported inpatient satisfaction as measured by HCAHPS survey scores remains unknown. To determine the impact of severity of illness on patients' self-reported inpatient satisfaction. The All Patient-Refined, Diagnosis Related Group (APR-DRG) classifies every patient into one of four levels of severity of illness. We evaluated the impact of APR-DRG severity of illness on five HCAHPS domains, two reputation and two environmental questions, using linear regression analysis. Adult inpatients discharged from a large, academic, tertiary care hospital. 37,223 patients' HCAHPS survey data were combined with their APR-DRG severity of illness rating over a 39-month period between April 2008 and June 2011. HCAHPS scores. Higher severity of illness was consistently and inversely associated with lower patients' self-reported perception of inpatient hospital satisfaction as measured by HCAHPS scores. For each one-unit increase in severity of illness, the average HCHAPS scores across all five domains were approximately 3 percent lower. Hospitals treating patients with a higher severity of illness will have lower HCAHPS scores, potentially leading these hospitals to receive lower reimbursement from CMS. Conversely, hospitals with lower severity of illness will receive greater reimbursement. Failure to adequately adjust for severity of illness is a serious flaw in the current HCAHPS reporting system that should be corrected.

Patient mobility for cardiac problems: a risk-adjusted analysis in Italy

BackgroundThe Italian National Health System was revised in the last 20 years, introducing new elements such as efficacy, efficiency and competitiveness. Devolution to regional authorities has created a quasi-market system where patients can choose the hospital in which to be treated. Patient mobility therefore becomes an indicator of perceived hospital quality and of financial flows between the regions of Italy. Previous studies analyzed patient mobility in general or by specific disease/diagnosis-related groups but there is a lack of research on the influence of severity of patient condition. The aim of the study was to describe patient mobility, crude and stratified by disease severity, in cardiac surgery units of three health areas (HAs) in Tuscany (Italy).MethodsIn this retrospective observational study, data was gathered from hospital discharge records obtained from the Tuscan Regional Health Agency, Italy. The three HAs (HA1, HA2, HA3) recorded 25,017 planned hospitalizations in cardiac surgery units in the period 2001–2007. Patients were stratified in four All Patient Refined Diagnosis Related Group (APR-DRG) severity levels. Gandy’s nomogram was used to describe how HAs met health care demand and their capacity to attract patients. Cuzick’s test was used to identify significant differences in time trends.ResultsRaw data showed that the HAs met their own local health care demand. Stratifying by APR-DRG severity, it emerged that capacity to meet local demand remained unchanged for zero-to-minor severity levels, but one HA was less able to meet demand for moderate severity levels or to attract patients from other HAs and Regions of Italy. In fact, HA3 showed a decrease in admissions of local residents.ConclusionsThe study highlights important differences between the three HAs that were only revealed by severity stratification: unlike HA3, HA1 and HA2 seemed able to deal with local demand, even after severity stratification. Planners and researchers can benefit from risk stratification data, which provides more elements for correct comparisons and interventions. In the context of patient mobility, the present study is a step in that direction.

Dopamine and Dobutamine Use in Preterm or Low Birth Weight Neonates in the Premier 2008 Database

Background Dobutamine and dopamine are off-patent drugs prioritized by the National Institute of Child Health and Human Development and US Food and Drug Administration for further study under the Best Pharmaceuticals for Children Act. Both agents are used to manage cardiac insufficiency in preterm neonates and are subject to controversy among neonatologists. Among the controversies are outcome measures (blood pressure vs end organ perfusion) and long-term effects. Objectives We analyzed retrospective hospitalization data to (1) describe the use of dopamine and dobutamine in low birth weight (LBW) or preterm infants in a large sample and (2) explore the potential of using observational data to describe outcomes in LBW or preterm infants treated with dopamine or dobutamine. Methods Inpatient data were extracted from the Premier database to calculate the prevalence of use of dopamine and dobutamine among neonates in 2008. Prevalence of use was calculated by categorizing patients as ever or never having received dopamine or dobutamine. We compared mortality in the neonates by using Cox proportional hazards models to identify variables associated with survival and to control for their effects. Results Out of 877,201 pediatric hospitalizations in 2008, 65,216 were neonates and had data available about dopamine and dobutamine use. Of these, 7459 were preterm or LBW and included 1143 very LBW (VLBW) neonates. Dopamine alone was given to 194 VLBW neonates, dobutamine alone was given to 14, and both dopamine and dobutamine were given to 79 neonates. For the VLBW neonates, probability of treatment with dopamine or dobutamine varied almost 10-fold from 4.4% to 38.4% at 11 hospitals and did not differ by 3M APR-DRG (all patient refined diagnosis related group) severity of illness or 3M APR-DRG risk of mortality. Conclusions Our data suggest the prevalence of dopamine or dobutamine use was 4.9% in preterm or LBW neonates and 25.1% in VLBW neonates. Treatment with dopamine alone was more common than treatment with dobutamine alone. There was no difference in mortality between neonates treated with dopamine compared with treatment with dobutamine, but access to charts and clinical details are required to conduct a comparative effectiveness study.

Economic Impact of Clostridium difficile Infection in a Multihospital Cohort of Academic Health Centers

To assess the economic impact of Clostridium difficile infection (CDI) in a large multihospital cohort. Retrospective case-control study. Administrative claims data from 45 academic medical centers. A total of 10,857 patients who developed health care-associated CDI and were discharged between April 1, 2002, and March 31, 2007 (cases); each case patient was matched by hospital, age, quarter and year of hospital discharge, and diagnosis related group to at least one control patient who did not develop health care-associated CDI (19,214 controls). Patients with health care-associated CDI were identified by using a previously validated method combining the International Classification of Diseases, Ninth Revision, Clinical Modification code for CDI with specific CDI drug therapy (oral or intravenous metronidazole, or oral vancomycin). Costs were determined from charges by using standardized cost:charges ratios and were adjusted for age, All Patient Refined-Diagnosis Related Group (APR-DRG) severity of illness level, race, and sex with use of multivariable linear regression. The adjusted mean cost for cases was significantly higher than that for controls ($55,769 vs $28,609), and adjusted mean length of stay was twice as long (21.1 vs 10.0 days). The interaction between CDI and APR-DRG severity of illness level was significant; the effect of CDI on costs and length of stay decreased as severity of illness increased. This large CDI economic evaluation confirms that health care-associated cases of CDI are associated with significantly higher mean cost and longer length of stay than those of matched controls, with the greatest effect on costs at the lowest level of severity of illness.

Determining benchmarks for evaluation and management coding in an academic division of general surgery1

Academic divisions of general surgery are facing ever-increasing financial pressures. Cost-cutting is a common approach to maintaining profitability, but strategies to increase revenue should not be ignored. One specific avenue for enhanced revenue generation in general surgery is that of coding for evaluation and management (E&M). Although this is the financial life-blood for many of the consultative services in departments of medicine, E&M coding is an often neglected and misunderstood component of surgical care. The financial records for the Division of General Surgery were reviewed for the period of January 2001 to June 2003. Specifically, charges and receipts for inpatient procedures and hospital visits (CPT codes 99231, 99232, and 99233) were determined. The analysis was limited to surgeons with a primary clinical focus based at the University hospital rather than the neighboring community or Veteran's Affairs hospitals. In addition, ICD-9 and All Patient Refined Diagnosis Related Groups (APR-DRG) data were analyzed to determine the surgeon-specific number of inpatients and inpatient-days with more than one ICD-9 code or secondary ICD-9 codes, or both, or an APR-DRG severity of illness score of 2, 3, or 4. These categories were defined to determine the number of inpatient-days for which E&M coding could be billed for management of secondary medical diagnoses. Analysis demonstrates that actual E&M charges were 40% to 47% of predicted minimums for E&M charges for the period under study. In theory, this result translates into an annual gain in receipts of 400,000 dollars to 600,000 dollars. We conclude that the ICD-9 and APR-DRG models may serve as benchmarks to determine the limits for E&M revenue stream, and E&M coding may represent an underutilized source of revenue among academic departments of surgery.

Does considering severity of illness improve interpretation of patient satisfaction data?

With the emergence of new, relatively low-cost code-based severity indexes, this question arises: Do complex descriptions of patient population in terms of severity yield a clearer picture of patients' opinions about hospital care and service? Consumers and third-party payers of healthcare are using patient satisfaction data with increasing frequency to evaluate the quality of care that hospitals provide. Insurers also use satisfaction data, when they are available, for contracting and ensuring provider accountability. The study described here examines whether the all patient refined-diagnosis related groups (APR-DRG) severity-of-illness rating system, in particular, can explain the variability in inpatient satisfaction ratings independently of patient demographics and clinical events. Multiple logistic regression was used on a data set of 3,720 patient records from one tertiary care facility, and model terms were fitted on the basis of reason for admission, year, gender, length of stay, age, and severity. The findings were that age and reason for admission were consistent predictors of high satisfaction on 14 survey items. APR-DRG severity was not a significant factor. Length of stay made a small but significant contribution on three items related to clinical quality.