Average Case Mix Index Research Articles

Efficiency and Resource Allocation in Government Hospitals in Saudi Arabi: A Casemix Index Approach.

In Saudi Arabia, the evaluation of healthcare institutions' performance and efficiency is gaining prominence to ensure effective resource utilization. This study aims to assess the efficiency of government hospitals in Saudi Arabia using the case mix index (CMI) approach. Comprehensive data from 67 MoH hospitals were collected and analyzed. The CMI was calculated by assigning weights to different patient groups based on case complexity and resource requirements, facilitating comparisons of hospital performance in terms of resource utilization and patient outcomes. The findings reveal variations in the CMI across hospitals in relation to size and type. The average CMI was 1.26, with the highest recorded at 1.67 and the lowest at 1.02. Medical cities demonstrated the highest CMI (1.47), followed by specialized hospitals (1.32), and general hospitals (1.21). The study highlights opportunities for enhancing productivity and efficiency, particularly in hospitals with lower CMI, by benchmarking against peer institutions with similar capacities and patient case mix. These findings have significant implications for hospital operations and resource allocation policies, supporting ongoing efforts to improve the efficiency of government hospitals in Saudi Arabia. By incorporating these insights into healthcare strategies, policymakers can work towards enhancing the overall performance and effectiveness of the healthcare system.

Economics of operating room use at auniversity eye hospital

In ophthalmologic surgery, there are usually short operation times and thus many changes between the individual operations, which are not subject to remuneration. As in maximum care hospitals consecutive different operations with different durations are often performed, emergency operations have to be inserted and further training of colleagues is practiced, it is particularly important to generate the shortest possible transfer times in order to have both sufficient operation time and to be able to treat as many cases as possible. The aim of this work is to evaluate the efficiency of the surgical performance of auniversity eye hospital. The surgeries performed in 2021 at the MHH Eye Clinic were evaluated with respect to the spectrum, number, surgery duration, transfer times and process times. In terms of personnel, each operating room was staffed with one assistant anesthesiologist, one nurse anesthetist, two operating room nurses, one surgeon, and 20% senior anesthesiologist supervision. Based on atheoretical concept, which provides an increased staffing ratio while maintaining the same infrastructure, it was calculated how many more surgeries could be performed if the transfer time was halved and whether the additional financial expense could be compensated. With atotal of n = 2712 surgeries performed during regular duty hours (244 working days) in 2 operating rooms (average daily n = 11.1; weekly n = 53.6 and monthly n = 237.1), the average surgery duration was 37 min and the transition time 43 min. This means that the operating rooms were used for surgery for 51% of the total operating time. Main procedures were vitrectomy with n = 1350 and cataract surgery with n = 1308. The new personnel concept provided one additional operating room nurse per operating room and one additional anesthesiologist for both operating rooms. The additional costs for this personnel expenditure were calculated at approx. 300,000 € per year. The halving of the transfer time from 43 min to about 21 min through possible overlapping induction and parallel work, which was not possible until now, results in an additional operation time of about 100 min per operating room, so that at least 4additional operations can be planned and performed. In this way, with stringent implementation and the same spatial structures with stable fixed costs, n = 976 more operations could be performed, which, minus the personnel costs, the additional material costs for surgery and anesthesia of 557,042 € and the inpatient hotel costs of 600,663 €, with an average length of stay of 2.8days, would result in an additional revenue of about 2.4times the additional personnel costs at the current flat rate of 3739.40 € and an average case mix index of the MHH Eye Hospital of 0.649 (total revenue: 2,155,449 €; profit marginII: 701,389 €) for the considered surgical patient collective in 2021. An increase of the personnel expenditure in the operating room for surgical subjects such as ophthalmology with shorter interventions and many changes is economically worthwhile also for alarge hospital in order to enable and optimize overlapping transfers of anesthesia and surgical care. This should therefore also be considered separately, contrary to standardized staffing of the overall hospital, in order to use existing resources with their fixed costs as optimally as possible.

Improving the clinical ability and quality of endocrinology department with diagnosis-related groups tool

BackgroundTo evaluate the use of the diagnosis-related groups (DRGs) tool to promote the diagnosis/treatment ability and quality of the endocrinology department under the new policy of grouping payment-related to disease diagnosis.MethodsWe compared the income structure of the endocrinology department in a 3a general hospital between the first half of 2019 and the same period in 2021. We also observed the changes in cost efficiency indexes (CEIs), time efficiency indexes (TEIs), case-mix index (CMI), number of DRGs, risk weight (RW) proportion, and surgery number in the inpatient department. Furthermore, the distribution of inpatients with diabetes of the whole hospital and the improvement of treatment efficiency indexes of the sub-specialty department were analyzed.ResultsIn the first half of 2021, compared with the same period of 2019, the total revenue of the endocrinology department decreased by 20.05%, the average hospitalization cost decreased by 11.72%, the CEI decreased from 1.31 to 1.06, and the TEI decreased from 0.74 to 0.64. Additionally, the number of DRGs increased from 162 to 176, the average CMI value increased from 0.80 to 0.84, and the proportion of RW 1–5 cases increased. Moreover, the number of surgical cases increased by 60.50%, minimally invasive surgery increased by 53.54%, grade 4 surgery increased by 66.67%, and the proportion of entering the clinical pathway increased from 77.76% to 86.64%. From May to August, 2021, the admission rate of endocrinology sub-specialty increased significantly, the number of DRGs showed an increasing trend, and the CEI and TEI decreased significantly. In the first half of 2021, inpatients with diabetes in the departments of rehabilitation, neurology, nephropathy, ophthalmology, and general administration accounted for 21.99–38.54%.ConclusionsThe DRGs tool can be used to improve the clinical diagnosis and treatment ability of the endocrinology department, as well as optimize the CEI, TEI, CMI, and RW values. It is an effective way to promote the development of the endocrinology department under the new DRGs payment policy, carry out blood glucose management in the hospital, build endocrinology sub-specialties, and improve surgical and operation capacity.

Prospective Interventions to Reduce Stroke Care Variation in a Hub-and-Spokes System

BackgroundCare variation reduction (CVR) is a central objective of quality management to decrease wasted spending. ObjectiveTo analyze stroke care variation at a hub-and-spokes system and determine interventions to prospectively reduce unwarranted variation. MethodsIn this prospective cohort single arm intervention study providers were blinded to pre-specified endpoints. Care variation was measured for DRGs 61-66 and 69 in USD, and severity level by Case Mix Index (CMI) by provider. A multi-disciplinary task force chaired by Vascular Neurologist analyzed data extracted from Crimson, a patient centric data analysis tool, and determined interventions. The primary measure outcome was change in CMI post intervention. ResultsAnnualized baseline care variation was $ 0.7-1.2M (2017) in a drip-and-ship thrombolytic treatment model within the hub-and-spokes system. Pharmacy expenses contributed to 42% of variation followed by laboratory 12%, physical therapy 11%, supplies 11% and imaging 9%. Interventions to achieve CVR were prospectively implemented in 2018 and CVR was measured in January 2019. Based on 2017 CMI of 1.28, the goal of intervention was set to achieve 7% increase to 1.37 with projected increased revenue of $774,144. After implementation of interventions the actual achieved average CMI in 2018 was 1.40 paralleled by improvement in secondary outcomes of length of stay, observed over expected mortality and re-admission. ConclusionsA drip-and-ship stroke model within a single hub-and-spokes healthcare system can achieve substantial reduction in care variation and associated cost along with improvement in patient care indicators.

10 years of hand traumatology - an epidemiological, structural and economic analysis at a maximum care provider

Hand surgery in Germany has been subject to structural changes that strongly affect the balance between medicine and economics. On the one hand there is a shift of elective hand surgery from the inpatient to the outpatient sector. On the other hand - so our observations - emergency hand trauma cases are more concentrated in bigger hospitals. Given this background there is a lack of statistical data on the management of hand trauma care and treatment of patients with hand injuries. This article discusses a 10-year-analysis of hand traumatological cases treated at a maximum care hospital regarding epidemiological, structural and economic aspects. Using a database query using ICD codes, inpatient hand trauma cases were identified between 2009-2018 and analyzed with regard to epidemiological and economic indicators (age, gender, comorbidities, case-mix-index (CMI), revenue, length of stay, length of surgery) using PIVOT tables. Patients under the age of 16 years, forearm fractures and intensive care patients were excluded. In the study period the typical hand surgical trauma patient was male with an average age of 44 years. The Patient-Clinical-Complexity-Level (PCCL) was 0 in 80 % of all cases. The proportion of work-related injuries averaged around 25 %. The three top diagnose related groups (DRG) were the I32F (18.5 %), X01B (11.3 %) and the I32A (7.2 %). A striking point was the massive increase in the overall number of trauma cases over the years from approx. 300 cases in 2009 to over 1000 cases per year in 2018 with a shift of the main workload to on-call and night-shift hours away from core working times. In the study period 4 of 5 others hospitals located in a distance of 100 km reduced and stopped treatment of emergency hand cases. The average length of a hospital stay was approx. 4-5 days, the average cut/suture time less than 60 minutes and the average CMI 1.23. Those cases generate an average proceed of € 4370 in 2018, whereby the cases generated by the work-related injuries averaged € 387 less. On the assumption that the number of emergency hand trauma cases did not really increase in the study period we think that there was a concentration of such cases in a few centres still providing extensive treatment for hand injuries while in smaller hospitals care for emergency hand trauma cases is progressively reduced. However, hand injuries may be worth a second thought for economic reasons because they can create reasonable revenues with rather little effort.If a critical number of patients is exceeded, costs of service provisions can be significantly amortized by the proceed generated by treatment. In those hospitals still taking care for acute hand injuries the workload especially in standby duty increased. What may have a negative input on the numbers of treated elective hand surgery cases.

The impact of comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study

BackgroundInfectious airborne and surface pathogens constitute a substantial and poorly explored source of patient subclinical illness and infections. With that in mind, a system of advanced air purification technology was designed to destroy the DNA and RNA of all bacteria, fungi, and viruses. This study compares the effects of advanced air purification technology versus high efficiency particulate air filtration with respect to certain metrics of health care economics and resource utilization at a large, community-based, urban hospital. Our hypothesis was that the use of the advanced air purification technology would decrease health care durations of stay, lead to fewer nonhome discharges, and decrease hospital charges. MethodsAfter the installation of advanced air purification technology, 3 resultant air purification “zones” were established: zone C, a control floor with high efficiency particulate air filtration; zone B, a mixed high efficiency particulate air and advanced air purification technology floor; and zone A, a comprehensive advanced air purification technology remediation. This study included nonbariatric surgical patients admitted to any zone between December 2017 and December 2018, with reported case mix index on discharge. We analyzed hospital duration of stays, discharge destination, and hospital charges with adjustment for severity of illness using the case mix index. The likelihood of mortality, health care-associated infection, and readmission for each study zone was examined using logistic regression adjusting for case mix index, age, sex, and source of admission. ResultsThe study included 1,002 patients across the 3 zones, with mean age of 55.8 years (53.7% female), average case mix index of 1.98, and mortality of 1.7%. Compared with zone C, patients in zones A and B demonstrated decreased hospital stays, a greater percentage of home discharges (86.5–87.8% vs 64.7%), and less hospital charges. In addition, logistic regression modeling performed on 999 study patients showed that the likelihood of mortality, hospital-acquired infections, and readmissions did not differ among the 3 zones. A trend toward a lesser incidence of hospital-acquired infections was noted in zones A and B (0.40% and 0.48%, respectively) when compared with zone C (0.63%). ConclusionPatients in the advanced air purification technology zones demonstrated statistically significant improvements in durations of stay, discharge to home, and costs after adjusting for case mix index. In addition, a trend toward fewer hospital-acquired infections in advanced air purification technology zones was noted. These findings suggest that environmental factors may affect key clinical and economic outcomes, supporting further research in this important and largely unexplored area.

Does Surgical Volume and Complexity Affect Cost and Mortality in Otolaryngology-Head and Neck Surgery?

(1) To evaluate whether admission volume and case complexity are associated with mortality rates and (2) evaluate whether admission volume and case complexity are associated with cost per admission. Retrospective case series. Tertiary academic hospital. The Vizient database was queried for inpatient admissions between July 2015 and March 2017 to an otolaryngology-head and neck surgery service. Data collected included admission volume, length of stay, intensive care unit (ICU) status, complication rates, case mix index (CMI), and cost data. Regression analysis was performed to evaluate the relationship between cost, CMI, admission volume, and mortality rate. In total, 338 hospitals provided data for analysis. Mean hospital admission volume was 182 (range, 1-1284), and mean CMI was 1.69 (range, 0.66-6.0). A 1-point increase in hospital average CMI was associated with a 40% increase in odds for high mortality. Admission volume was associated with lower mortality, with 1% lower odds for each additional case. A 1-point increase in CMI produces a $4624 higher total cost per case (95% confidence interval, $4550-$4700), and for each additional case, total cost per case increased by $6. For otolaryngology inpatient services at US academic medical centers, increasing admission volume is associated with decreased mortality rates, even after controlling for CMI and complication rates. Increasing CMI levels have an anticipated correlation with higher total costs per case, but admission volume is unexpectedly associated with a significant increase in average cost per case.

Back to the Future: Impact of a Paper-Based Admission H&P on Clinical Documentation Improvement at a Level 1 Trauma Center

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group (P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

Venous Thromboembolism Rates in Transferred Patients: A Cross-Sectional Study.

Patients undergoing a transfer during a hospitalization may be more likely to be diagnosed with a venous thromboembolism (VTE) than patients who are not transferred. To determine whether transferred patients have an increased prevalence of VTE diagnosis. This was a cross-sectional study comparing VTE diagnosis rates between transferred patients and non-transferred patients. For the years 2012-2014, the University HealthSystem Consortium database of multiple community and academic medical centers throughout the United States was parsed using ICD-9 VTE diagnosis codes and patient's point of origin. Patients were included in the analysis as transferred patients if their point of origin was a skilled nursing facility, another acute care facility or another facility. Non-transferred patients were those whose point of origin was a clinic or those with a non-facility point of origin. The primary comparison of VTE prevalence during hospitalization between transferred and non-transferred patients in the years 2012-2014. Subgroup analysis looked at level I trauma status and case mix index (CMI) to determine whether these had an effect on VTE prevalence. From 2012 to 2014, a total of 225 unique hospitals and 12,036,029 patients were analyzed, and the prevalence of VTE in transferred patients and non-transferred patients was 3.43% and 1.91% (RR 1.80; 95% CI 1.78-1.81; P<0.001), respectively. VTE prevalence in transferred versus non-transferred patients at level I trauma centers was 3.42% versus 1.88% (RR=1.82; 95% CI 1.80-1.85; P<0.001). The 3-year average CMI of transferred versus non-transferred patients was 3.53 versus 2.26 (P< 0.001). Transferred patients have a higher prevalence of VTE than non-transferred patients, regardless of level I trauma designation. Higher VTE rates in transferred versus non-transferred patients was minimally correlated with CMI.

Seasonal distribution of clinical case codes (DOC study)

The German diagnosis-related groups remuneration system (G-DRG) was implemented in 2004 and patient-related diagnoses and procedures lead to allocation to specific DRGs. This system includes several codes, such as case mix (CM), case mix index (CMI) and number of cases. Seasonal distribution of these codes as well as distribution of diagnoses and DRGs may lead to logistical consequences for clinical management. From 2004 to 2013 all the main diagnoses and DRGs for inpatients were recorded. Monthly and seasonal distributions were analyzed using ANOVA. The average monthly number of cases was 265 ± 25 cases, the average CM was 388.50 ± 51.75 and the average CMI was 1.46 ± 0.15 with no significant seasonal differences (p > 0.1). Concussion was the most frequently occurring main diagnosis (3739 cases) followed by fractures of the humeral head (699). Significant distribution differences could be shown for humeral head fractures in monthly (p = 0.018) and seasonal comparisons (p = 0.006) with a maximum in winter. Radius (p = 0.01) and ankle fractures (p ≤ 0.001) also occurred most frequently in winter. Non-bony lesions of the shoulder were significantly less in spring (p = 0.04). The DRGs showed no evidence of a monthly or seasonal clustering (p > 0.1). The significant clustering of injuries in specific months and seasons should lead to logistic consequences (e.g. operating room slots, availability of nursing and anesthesia staff). For a needs assessment the analysis of main diagnoses is more appropriate than DRGs.

Abstract 19519: Closing the Cardiac Intensive Care Unit: Cost-Savings Associated with a “Closed” versus “Open” Model of Critical Care Delivery

Introduction: A recent AHA scientific statement highlighted the evolving complexity of critical care delivery for cardiac patients, and the emerging need for novel staffing models. In this document, a “closed” unit structure - in which a dedicated intensive care team treats all admitted patients - was specifically advocated. However, in light of escalating critical care costs within US hospitals, there is a pressing need to better understand the financial impact of different care platforms. Methods: In July 2013, our academic cardiac intensive care unit (CICU) was transitioned from an “open” to a “closed” model of care. In a before-and-after study design, consecutive admission records were reviewed from Aug 2012-Dec 2012 (“open” unit) and from Aug 2013-Dec 2013 (“closed” unit). Routinely collected financial and demographic data were examined, and the impact of case-mix index (CMI) on cost was evaluated. Results: In the “open” and “closed” models, there were 333 patient-visits accounting for 1,891 patient-days and 397 visits accounting for 2,558 patient-days, respectively. While demographics, payor mix, and fixed vs. variable cost distribution were unchanged (Table), the total cost-per-patient and cost-per-patient-day were lower within the “closed” CICU ($8,676 vs. $10,118 and $1,346 vs. $1,782, respectively) despite a greater average CMI (4.6 vs. 3.6). Total and 30d CICU readmission rates were also lower in the “closed” unit (Table). Readmissions in the "closed" unit resulted in greater cost-per-patient-day than new admits ($1,576 vs. $1,339). Conclusions: A “closed” CICU staffing model is associated with lower health care costs. This may be partly explained by lower CICU recidivism, but likely is multifactorial. Additional study will focus on the influence of resource use, critical care delivery to key sub-populations, and the development of effective strategies for further cost containment.

Embedding palliative care into care coordination.

62 Background: The Institute of Medicine (IOM) identified care coordination as a key strategy with potential to improve the safety and effectiveness of implemented care by deliberately organizing patient care activities and sharing information among all participants concerned. Palliative care maximizes quality of life for patient and family in serious illness and can be provided early and concurrently with curative therapies. At City of Hope National Medical Center (COH), we developed a pilot program for bladder cancer patients undergoing cystectomy to provide the benefits of care coordination and palliative care. Methods: 72 patients underwent cystectomy at COH from 2011-2013, the average case mix index was 3.51, the average length of stay (LOS) was 10.65 days, the LOS index was.92, Cost index 1.61, 30-day readmission rate 32.14%, and the most common causes for readmission were infection and dehydration. Based on comparative data, the urology service supported development of a novel pathway by a multidisciplinary team. The goals of the pathway are to facilitate navigation through the healthcare system, integrate tablet-based bio-psycho-social screening to proactively address patient and caregiver needs and goals, optimize medications to improve symptom management and recovery, empower patients with teach-back education, have anticipated interventions for likely readmission reasons, and develop effective collaboration amongst multidisciplinary providers across settings. The metrics include LOS, readmission rates, patient and family satisfaction, advanced directives on file, and cost index. Results: Hospital leadership and provider buy in was obtained, a daily rounding multidisciplinary team was created, change champions were identified, staff engagement increased, and COH and community agency staff were equipped with needed skills and support. Care model diagrams and clinical pathway orders were developed. Education materials were revised and updated. The pilot launched in April of 2014. Conclusions: We believe that a care coordination model with early integration of palliative care will improve the effectiveness of care delivered to our bladder cancer patients. A six-month retrospective review will be done to assess metric achievement.

Impact of Hospital Variables on Case Mix Index as a Marker of Disease Severity

Case mix index (CMI) has become a standard indicator of hospital disease severity in the United States and internationally. However, CMI was designed to calculate hospital payments, not to track disease severity, and is highly dependent on documentation and coding accuracy. The authors evaluated whether CMI varied by characteristics affecting hospitals' disease severity (eg, trauma center or not). The authors also evaluated whether CMI was lower at public hospitals than private hospitals, given the diminished financial resources to support documentation enhancement at public hospitals. CMI data for a 14-year period from a large public database were analyzed longitudinally and cross-sectionally to define the impact of hospital variables on average CMI within and across hospital groups. Between 1996 and 2007, average CMI declined by 0.4% for public hospitals, while rising significantly for private for-profit (14%) and nonprofit (6%) hospitals. After the introduction of the Medicare Severity Diagnosis Related Group (MS-DRG) system in 2007, average CMI increased for all 3 hospital types but remained lowest in public vs. private for-profit or nonprofit hospitals (1.05 vs. 1.25 vs. 1.20; P<0.0001). By multivariate analysis, teaching hospitals, level 1 trauma centers, and larger hospitals had higher average CMI, consistent with a marker of disease severity, but only for private hospitals. Public hospitals had lower CMI across all subgroups. Although CMI had some characteristics of a disease severity marker, it was lower across all strata for public hospitals. Hence, caution is warranted when using CMI to adjust for disease severity across public vs. private hospitals.

The contribution of staff call light response time to fall and injurious fall rates: an exploratory study in four US hospitals using archived hospital data

BackgroundFall prevention programs for hospitalized patients have had limited success, and the effect of programs on decreasing total falls and fall-related injuries is still inconclusive. This exploratory multi-hospital study examined the unique contribution of call light response time to predicting total fall rates and injurious fall rates in inpatient acute care settings. The conceptual model was based on Donabedian's framework of structure, process, and health-care outcomes. The covariates included the hospital, unit type, total nursing hours per patient-day (HPPDs), percentage of the total nursing HPPDs supplied by registered nurses, percentage of patients aged 65 years or older, average case mix index, percentage of patients with altered mental status, percentage of patients with hearing problems, and call light use rate per patient-day.MethodsWe analyzed data from 28 units from 4 Michigan hospitals, using archived data and chart reviews from January 2004 to May 2009. The patient care unit-month, defined as data aggregated by month for each patient care unit, was the unit of analysis (N = 1063). Hierarchical multiple regression analyses were used.ResultsFaster call light response time was associated with lower total fall and injurious fall rates. Units with a higher call light use rate had lower total fall and injurious fall rates. A higher percentage of productive nursing hours provided by registered nurses was associated with lower total fall and injurious fall rates. A higher percentage of patients with altered mental status was associated with a higher total fall rate but not a higher injurious fall rate. Units with a higher percentage of patients aged 65 years or older had lower injurious fall rates.ConclusionsFaster call light response time appeared to contribute to lower total fall and injurious fall rates, after controlling for the covariates. For practical relevance, hospital and nursing executives should consider strategizing fall and injurious fall prevention efforts by aiming for a decrease in staff response time to call lights. Monitoring call light response time on a regular basis is recommended and could be incorporated into evidence-based practice guidelines for fall prevention.

G-DRG Version 2009: New Developments

The update of the G-DRG system for the year 2009 has been successfully negotiated. Like in the past years, changes are minimal and not dramatic, but they significantly enhance the quality of the DRG system. Once again, the German DRG system demonstrates its versatility and reliability for clinical reimbursement purposes. In the field of dermatology, several improvements or enhancements can be identified; the average case mix index that declined in the past years should now rise by 0.5 percent for 2009. Oncology cases are affected especially by this increase. Some refinements advanced for several years by the German Dermatologic Society (DDG) have been recognized --complex therapies like vacuum wound therapy, isolation due to multi-resistant infections and multiple primary tumors now have better cost weights. Although there still remain some minor problems like reimbursement of cost-intensive treatments, German dermatology is in summary very well prepared for the year 2009.

Quality Indicators in the Department of Veterans Affairs Nursing Home Care Units: A Preliminary Assessment

The authors analyzed the minimum data set quality indicators data aggregated nationally from 134 Department of Veterans Affairs nursing home care units with more than 15,000 long-stay residents (>90 days) yearly for federal fiscal years 2003, 2004, and 2005. Despite an increase in the severity of illness and complexity of services as determined by the minimum data set case-mix indices, most of the minimum data set quality indicators showed an improvement (rate decrease) from fiscal year 2003 to fiscal year 2005, whether examined on a year-to-year basis or by an overall 3-year trend. Nationally, there was a 5.1% increase in average case-mix index, while 14 of 24 quality indicators showed a decrease in the prevalence/ incidence rates and only 4 quality indicators showed increased rates. These minimum data set results provide important information for Veterans Affairs quality managers regarding areas of achievement and also identify areas to be targeted for future quality improvement.

A PROGRAM TO REDUCE DISCHARGE DELAYS IN AN NICU. 1412

We wished to test the hypothesis that a program designed to identify the causes of discharge delays (DD) would significantly reduce the length of stay in our metropolitan academic regional NICU. We reviewed all admissions from January 1994 through November 1995 (n=1396). A DD was defined as any delay in discharge not related to illness after the attending neonatologist cleared the baby for release. DDs were further divided according to cause into medical, administrative, social work, family-related, and “other” categories. All admissions were reviewed by one of the authors. Potential DDs were identified and tracked daily according to established criteria. Actual DDs were then reviewed on a monthly basis at an open staff meeting attended by representatives our multi-disciplinary team. 111 DDs accounting for 481 patient days were identified, 83 DD/302 patient days in 1994 and 28 DD/179 patient days in 1995. 13.9% of DDs weighed <1000 gms. at birth, and 35.6% were <1500 gms. at birth. DDs ranged from 1-34 days, with an average of 4.3 days added/case. Babies with DDs had a case mix index (CMI) of 9.70. The average CMI for the NICU during 1994 was 6.25, and for 1995 to date was 5.18, with an overall average of 5.71 for the entire period. 44% of DDs had private insurance, 55% had Medicaid, and 1% were self-pay. 84/111 DDs were caused by circumstances beyond the control of the primary care team. A further 24/111 DDs were the result of our policy requiring a 48-hour period free of apnea/bradycardia alarms prior to discharge. Average savings per day were based on the diagnosis-related group (DRG) of each DD patient. Discharge delays for 1994 cost $226,298. ($749/day). For 1995, DDs cost $36,132($202/day), for a total cost of $262,431. Total savings in 1995 vs. 1994 was$190,166 ($548/day). Despite their low birth weight and relatively severe illness (high CMI), we believe that heightened staff awareness and ongoing monitoring of potential DDs can result in a significant reduction in length of stay and a significant cost savings.