Case Mix Groups Research Articles

Reporting units in life-cycle assessments of hospitals: a systematized review of the literature

Abstract Purpose
This systematized literature review aims to assess reporting units used by hospital LCAs to communicate their environmental impact through life-cycle assessment. As the healthcare sector increasingly prioritizes sustainability, understanding the choice of reporting unit is crucial. This analysis aims to provide recommendations for effective communication of environmental performance.
Method
A systematized literature search was conducted for life-cycle assessments and carbon footprint studies of healthcare organizations or systems in the databases PubMed and Web of Science. The identified units were analyzed using seven criteria, including the differentiation between input and output flows, treatment complexities, quantity of provided services, quality of provided services, longevity of services, matching with system boundaries, and data availability.
Results
Seven reporting flows were identified: (i) floor area, (ii) number of beds, (iii) workforce, (iv) expenditure, (v) patient load, (vi) revenue, and (vii) the diagnosis-related groups case mix. Each flow has its own advantages and disadvantages; the best reporting flow for an assessment depends on the specific goals and objectives and should be meaningful to stakeholders. However, none of the reporting flows measure the actual function of healthcare organizations, i.e., the impact on the health of the patients. However, data on this flow, such as quality-adjusted life years, are not available in a meaningful quantity.
Conclusions
In conclusion, this literature review highlights the importance of reporting unit selection in communicating the environmental impact of healthcare organizations through life-cycle assessment. The present analysis identified seven reporting flows, each with its own advantages and disadvantages. These findings are of importance for decision makers to contextualize given data and to choose the most suitable reporting flow for their own assessment. Future research might evaluate the quantitative impact of the reporting flow decision.

Trends in the characteristics and outcomes of older patients with non-traumatic spinal cord injury treated in inpatient rehabilitation facilities: 2013–2018

Objective To describe the characteristics and outcomes of older (≥ 65 years of age) patients with a non-traumatic spinal cord injury (NTSCI) treated in inpatient rehabilitation facilities (IRFs) between 2013 and 2018. Design Observational study. Setting IRFs in the United States. Participants 93,631 IRF Medicare stays for patients with NTSCI. Interventions Not Applicable. Main Outcome Measures Length of stay, self-care and mobility function, discharge destination. Results Between 2013 and 2018, the number of older (≥ 65 years of age) Medicare patients with a NTSCI treated in IRFs increased about 22.1 percent, from 14,149 to 17,275. In addition to the increase, patients’ sociodemographic characteristics shifted to have a slightly higher percentage of patients aged 65–74 years, a slightly higher percentage of males, and slightly fewer patients who identified as Hispanic. There was also a trend of more patients in the higher acuity case-mix groups and comorbidities tiers, but the median length of stay remained 12 days across all years. The percent of patients discharged home or to a community-based setting varied from 73.7 to 75.2 without a trend, although discharge self-care and mobility function increased slightly across the years. Conclusions Between 2013 and 2018, the number of Medicare patients with NTSCI treated in IRFs increased by more than 22 percent. While patient complexity increased, the median length of stay remained 12 days across the years. Discharge self-care and mobility function increased slightly, and the percent of patients discharged home ranged from 73.7 to 75.2 across the years.

Validation of a Costing Algorithm and Cost Drivers for Neonates Admitted to the Neonatal Intensive Care Unit.

Neonatal intensive care units (NICUs) account for over 35% of pediatric in-hospital costs. A better understanding of NICU expenditures may help identify areas of improvements. This study aimed to validate the Canadian Neonatal Network (CNN) costing algorithm for seven case-mix groups with actual costs incurred in a tertiary NICU and explore drivers of cost. A retrospective cohort study of infants admitted within 24 hours of birth to a Level-3 NICU from 2016 to 2019. Patient data and predicted costs were obtained from the CNN database and were compared to actual obtained from the hospital accounting system (Coût par Parcours de Soins et de Services). Cost estimates (adjusted to 2017 Canadian Dollars) were compared using Spearman correlation coefficient (rho). Among 1,795 infants included, 169 (9%) had major congenital anomalies, 164 (9%) with <29 weeks' gestational age (GA), 189 (11%) with 29 to 32 weeks' GA, and 452 (25%) with 33 to 36 weeks' GA. The rest were term infants: 86 (5%) with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia, 194 (11%) requiring respiratory support, and 541 (30%) admitted for other reasons. Median total NICU costs varied from $6,267 (term infants admitted for other reasons) to $211,103 (infants born with <29 weeks' GA). Median daily costs ranged from $1,613 to $2,238. Predicted costs correlated with actual costs across all case-mix groups (rho range 0.78-0.98, p < 0.01) with physician and nursing representing the largest proportion of total costs (65-82%). The CNN algorithm accurately predicts NICU total costs for seven case-mix groups. Personnel costs account for three-fourths of in-hospital total costs of all infants in the NICU. · Very preterm infants born below 33 weeks of gestation account for most of NICU resource use.. · Human resources providing direct patient care represented the largest portion of costs.. · The algorithm strongly predicted total costs for all case-mix groups..

Moving towards a continuous health care system—payment reform for post-acute care in Changsha City Of China

Introduction: As an integral component of a healthcare system，PAC is not fully developed in China largely attributing to the lack of sound medical insurance coverage and payment for PAC . Changsha City in the middle-south of China draws on international experience to carry out the value-based payment reform for post-acute rehablitation, in order to facilitate the development of rehablitative system and promote the continuity and integration of current health care system. &#x0D; Practice change implementation: According to the characteristics and rehabilitation intensity of inpatients, rehabilitation treatment is divided into two stages: recovery stage and chronic stage. For each stage, different patient classification systems are applied. For recovery phase Functional-Related Groups（FRGs）,a case based payment system is established locally. For chronic phase, payment is made on per-diem basis, and Patient-Driven Chronic Rehabilitation Groups (PDCRG) are applied as casemix groups. The adapted version of International Classification of Functioning, Disability and Health(ICF) scale is used to collect patient data as well as measure their functional gain, which enables the implementation of value-based payment. &#x0D; Aim and theory of change: The pilot reform is to support the effective and quality delivery of rehabilitation services, promote the development of PAC system, and push forward the value-based payment of the medical insurance.&#x0D; Targeted population and stakeholders: ·Inpatients with intensive or chronic rehabilitation needs in Changsha City&#x0D; ·Rehabilitation service providers (including general hospitals, public and private rehabilitation specialist hospitals and other facilities providing medical rehabilitation services）in Changsha City&#x0D; ·Social Medical Insurance Department of Changsha City&#x0D; Timeline: The payment policy was introduced in Jun. 2022 and the development is ongoing. &#x0D; Highlights: The key outcomes, impact and innovation include:&#x0D; ·Continuous rehabilitation: recovery stage and chronic stage, with acute care before and long-term care after&#x0D; ·The refinement of ICF assessment scale to local practice and the development of PAC insurance information system based on the assessment&#x0D; ·Value-based payment: provide a method to measure the functional gain of rehabilitation inpatients and link hospital payment to patient outcomes&#x0D; ·Offer practical experience for reform of medical insurance payment mode of rehabilitation&#x0D; Sustainability: ·The proposed mode stimulates the development of rehabilitation care services, meanwhile, decreases the burden on the medical and long-term care systems&#x0D; ·As a supplement of other payment modes, value-based payment mode fills the gap of rehabilitation medical insurance and supports integration of medical services.&#x0D; Transfer-ability: Nowadays, China has been pushing ahead with the payment reform of acute hospitalization and developing long-term care insurance for disabled elderly. The Value-based payment model for PAC could reliably classify the needs of rehabilitation inpatients, promoting the development of PAC system. There is significant potential for the model to be replicated.&#x0D; Conclusions (comprising key findings, discussion and lessons learned): Aimed at building a sound payment system for post-acute rehabilitaion, the payment reform for PAC in Changsha put forward a value-oriented payment model based mainly on patients’ functional conditions and classified rehabilitative patients into two stages. In the future, the criteria of the two stages and the referral mechanisms in the system need to be further explored and established.

Case mix-based changes in health status: A prospective study of elective surgery patients in Vancouver, Canada.

Hospital activity is often measured using diagnosis-related groups, or case mix groups, but this information does not represent important aspects of patients' health outcomes. This study reports on case mix-based changes in health status of elective (planned) surgery patients in Vancouver, Canada. We used a prospectively recruited cohort of consecutive patients scheduled for planned inpatient or outpatient surgery in six acute care hospitals in Vancouver. All participants completed the EQ-5D(5L) preoperatively and 6months postoperatively, collected from October 2015 to September 2020 and linked with hospital discharge data. The main outcome was whether patients' self-reported health status improved among different inpatient and outpatient case mix groups. The study included 1665 participants with completed EQ-5D(5L) preoperatively and postoperatively, representing a 44.8% participation rate across eight inpatient and outpatient surgical case mix categories. All case mix categories were associated with a statistically significant gain in health status (p < .01 or lower) as measured by the utility value and visual analogue scale score. Foot and ankle surgery patients had the lowest preoperative health status (mean utility value: 0.6103), while bariatric surgery patients reported the largest improvements in health status (mean gain in utility value: 0.1515). This study provides evidence that it was feasible to compare patient-reported outcomes across case mix categories of surgical patients in a consistent manner across a system of hospitals in one province in Canada. Reporting changes in health status of operative case mix categories identifies characteristics of patients more likely to experience significant gains in health.

Cost Estimations of Managing Adverse Drug Reactions in Hospitalized Patients: A Systematic Review of Study Methods and Their Influences

This study aimed to systematically review and explore the impact of study methods on the cost of managing adverse drug reactions (ADRs) among hospitalized patients to guide policymakers and researchers. A literature search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library, and Google Scholar. The search was restricted to studies from 2000 to 2017. Two authors independently reviewed the studies, assessed their risk of bias, and extracted information for analysis. Data abstraction was based on the study design, ADR reporting, and costing approaches. Of 677 studies identified, 12 were included for analysis. All studies defined ADR according to WHO classifications. The percentage of admission due to ADR ranged from 0.03% to 17.11%. All studies adopted a healthcare provider perspective, using either a micro-costing (n = 7), case-mix group costing (n = 3), or average-per-diem costing (n = 2) approach. The cost per ADR widely fluctuated from USD 65.00 to USD 12,129.90 based on various factors. The micro-costing approach generally had a lower cost compared to other approaches. The cost per ADR in high-income countries was also 10 times higher than in lower- or middle-income countries. This study evidenced that the methodological heterogeneity across studies has resulted in a wide range of cost estimations for ADR management.

Clinical Coding Error With Potential Loss Of Hospital Income During Implementation Of The Indonesian Case Base Groups Casemix System

The diagnostic code is also the basis for determining the cost of health services. Diagnostic codes that are not qualified will cause losses to the hospital both financially and in policy making. This research method uses qualitative research methods. by using a case study approach (case study). The population which is used are medical record documents of inpatients at dr. Soeratno Gemolong Hospital in Trisemester 4 (October, November, December) in 2019, obtained a sample of 80 documents from a population of 804 documents. The sampling technique used is simple random sampling. The results of the study that the coding accuracy of the Casemix Indonesian Case Base Groups (INA-CBGs) system at Dr. Soeratno Gemolong Hospital Sragen Hospital there are 42 accurate diagnosis codes and 38 inaccurate diagnosis codes, while the inaccuracy of the diagnosis code is caused by the coding error of the main diagnostic code, coding error of the Secondary diagnosis code, coding error &nbsp;Primary and secondary diagnosis code and coding error of the Diagnosis and procedure code. There is a difference between the claim rate from the inaccurate coding and the claim rate from the accurate coding, where the inaccurate coding claim rate generates revenue for the hospital of IDR. 22,816,048 whereas if the claim rate from the correct coding will result in an additional IDR. 41,221,848 for the hospital, so that due to the coding error, the hospital will experience a decrease in income or loss of IDR.18,405,800.

Association between physician continuity of care and patient outcomes in clinical teaching units: a cohort analysis.

Hospital-based clinical teaching units (CTUs) are supervised by rotating attending physicians. Physician hand-offs in other contexts have been associated with worse patient outcomes, presumably through communication gaps. We aimed to determine the association between attending physician hand-offs on CTUs and patient outcomes including escalation of care, readmission and mortality. We conducted a retrospective, multicentre cohort study using data from 3 tertiary care hospitals in Calgary between Jan. 1, 2015, and Dec. 31, 2017. We included hospital admissions in the top 10 case-mix groups. Our exposure variable was the number of attending physicians seen by a patient. Outcome measures were admission to intensive care unit (ICU); inpatient 7- and 30-day mortality; and 7- and 30-day readmission rate. We used multivariable regression statistical models adjusted for patient age, sex, length of stay, Charlson Comorbidity Index, case-mix groups, senior resident presence, team handovers and team transfers. Our cohort included 4324 unique patients. There were no significant differences in the incidence rate ratios (IRRs) of admission to ICU, inpatient 7- and 30-day mortality, and 7- and 30-day readmission rates among 1 or 2 physicians. However, we noted a significant increase in 30-day readmission rate (IRR 1.37, 95% confidence interval 1.05-1.78) in patients who had 3 or more attending physicians compared with those who had 1 attending physician. We found that 2 or more physician hand-offs on CTUs had a modestly greater association with patient readmission at 30 days. More research is needed to explore this finding and to evaluate associated patient and resource outcomes with physician hand-offs.

590 Influence of Hospital Characteristics on Patient Outcomes Following Cancer Surgery: An International, Mixed Methods Study Across 66 Countries

Abstract Aim Early death after cancer surgery is higher in low- and middle-income settings, yet the impact of hospital characteristics on early postoperative outcomes following cancer surgery worldwide are unknown. Method A mixed-methods analysis was performed using data from the GlobalSurg 3 study, a multicentre, international prospective cohort study of patients who underwent surgery for breast, gastric or colorectal cancer. The primary outcomes were 30-day mortality and major complication rates. Hierarchical clustering identified distinct hospital characteristics to create a facility capacity framework. Adjusted outcomes were determined after accounting for patient characteristics and country-income group. Results Hospital-level data were available for 9685 patients across 238 hospitals. The facility capacity framework consisted of seven distinct hospital resources and processes: presence of CT scan, postoperative recovery area, critical care facilities, opioid analgesia availability, oncologist, pathology and radiotherapy services. While complication rates were similar across hospitals with varying facility capacities, hospitals with five or less capacities (116 hospitals, 2251 patients) had increased mortality (aOR 1.67, 95% CI 1.13-2.48; P = 0.010). After adjustment for case-mix and country income group, patients undergoing surgery for gastric and colorectal cancer in hospitals with reduced capacities had higher mortality (6.2 vs. 4.0%; P &amp;lt; 0.001), predominantly explained by limited capacity to rescue following the development of major complications (61.3 vs. 72.1%; P &amp;lt; 0.001). Conclusions Hospitals with certain system capacities achieve better outcomes following cancer surgery, independent of country-income group. For cancers amenable to surgical treatment, national cancer care plans should include both surgical capacity building and concurrent hospital facility development to maximise reductions in cancer-associated mortality.

Association Between Health System Factors and Utilization of Routine Laboratory Tests in Clinical Teaching Units: a Cohort Analysis.

Few studies have looked at health system factors associated with laboratory test use. To determine the association between health system factors and routine laboratory test use in medical inpatients. We conducted a retrospective cohort study on adult patients admitted to clinical teaching units over a 3-year period (January 2015 to December 2017) at three tertiary care hospitals in Calgary, Alberta. Patients were assigned to a Case Mix Group+ (CMG+) category based on their clinical characteristics, and patients in the top 10 CMG+ groups were included in the cohort. The examined health system factors were (1) number of primary attending physicians seen by a patient, (2) number of attending medical teams seen by a patient, (3) structure of the medical team, and (4) day of the week. The primary outcome was the total number of routine laboratory tests ordered on a patient during their admission. Statistical models were adjusted for age, sex, length of stay, Charlson comorbidity index, and CMG+ group. The final cohort consisting of 36,667 patient-days in hospital (mean (SD) age 62.5 (18.4) years) represented 5071 unique hospitalizations and 4324 unique patients. Routine laboratory test use was increased when patients saw multiple attending physicians; with an adjusted incidence rate ratio (IRR) of 1.46 (95% CI, 1.37-1.55) for two attending physicians, and 2.50 (95% CI, 2.23-2.79) for three or more attending physicians compared to a single attending physician. The number of routine laboratory tests was slightly lower on weekends (IRR 0.98, 95% CI, 0.96-0.99) and on teams without a senior resident as part of their team structure (IRR 0.89, 95% CI 0.830.96). The associations observed in this study suggest that breaks in continuity of care, including increased frequency in patient transfer of care, may impact the utilization of routine laboratory tests.

External validation of the modified LACE+, LACE+, and LACE scores to predict readmission or death after hospital discharge.

Unplanned hospital readmissions are common adverse events. The LACE+ score has been used to identify patients at the highest risk of unplanned readmission or death, yet the external validity of this score remains uncertain. We constructed a cohort of patients admitted to hospital between 1 October 2014 and 31 January 2017 using population-based data from British Columbia (Canada). The primary outcome was a composite of urgent hospital readmission or death within 30 days of index discharge. The primary analysis sought to optimize clinical utility and international generalizability by focusing on the modified LACE+ (mLACE+) score, a variation of the LACE+ score which excludes the Case Mix Group score. Predictive performance was assessed using model calibration and discrimination. Among 368,154 hospitalized individuals, 31,961 (8.7%) were urgently readmitted and 5428 (1.5%) died within 30 days of index discharge (crude composite risk of readmission or death, 9.95%). The mLACE+ score exhibited excellent calibration (calibration-in-the-large and calibration slope no different than ideal) and adequate discrimination (c-statistic, 0.681; 95%CI, 0.678 to 0.684). Higher risk dichotomized mLACE+ scores were only modestly associated with the primary outcome (positive likelihood ratio 1.95, 95%CI 1.93 to 1.97). Predictive performance of the mLACE+ score was similar to that of the LACE+ and LACE scores. The mLACE+, LACE+ and LACE scores predict hospital readmission with excellent calibration and adequate discrimination. These scores can be used to target interventions designed to prevent unplanned hospital readmission.

PP265 Application Of A Case-Mix Method For Medical Consumables Management In Anhui Province, China Using Healthcare Big Data

IntroductionThe case-mix method involves combining cases with similar complexities and medical services. The process of treating one episode of the disease and receiving treatment is the research unit, thus achieving different medical units. The feasibility of the calculation method is verified by calculating the public hospital consumption ratio, medical income, health materials expenditure indicators, and the differences between the various types of surgical combinations. A decision-making basis can then be provided for the creation of government indicator standards.MethodsMedical records and data on the expenditure of medical consumables for the first and fourth quarters of 2017 were collected from seven third-class provincial hospitals. The medical consumption ratio for different diseases and surgical methods was calculated for the case-mix groups using a weighting method. Data were analyzed by descriptive statistics and the independent samples t-test.ResultsThere were significant differences in the proportions of combined use for different types of diseases. The same combination also had significant differences between different hospitals. In the fourth quarter of 2017, the operating group's consumption ratio was significantly lower than in the first quarter (p = 0.000).ConclusionsIt is reasonable to calculate the proportion of consumption by combined weighted analysis, which is also fairer for hospitals with better technical levels. This calculation method can be used by governments to manage the use and cost of medical consumables in hospitals.

Throughput interventions to reduce emergency department crowding: A systematic review

Emergency department (ED) throughput efficiency is largely dependent on staffing and process, and many operational interventions to increase throughput have been described. We systematically searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials to find studies describing the impact of throughput strategies on ED length of stay and left without being seen rates. Two independent reviewers screened studies, evaluated quality and risk of bias, and stratified eligible studies by intervention type. We assessed statistical heterogeneity using the chi-squared statistic and the I-squared (I2) statistic, and pooled results where appropriate. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Ninety-four (94) studies met inclusion criteria (Cohen's k = 0.7). Most were observational, five were determined to be low quality (Cohen's k = 0.6), and almost all reported modest reductions in length of stay and left without being seen rates, although there was substantial variability within and between intervention types. Fast track and patient streaming interventions showed the most consistent reduction in length of stay and left without being seenrates. Shifting high-level providers to triage appears effective and generally cost neutral. Evidence for enhanced testing strategies and alternative staffing models was less compelling. Introducing a fast track and optimizing processes for important case-mix groups will likely enhance throughput efficiency. Expediting diagnostic and treatment decisions by shifting physician-patient contact to the earliest possible process point (e.g., triage) is an effective cost-neutral strategy to increase flow. Focusing ED staff on operational improvement is likely to improve performance, regardless of the intervention type.

Regional Variations in Rehabilitation Outcomes of Adult Patients With Traumatic Brain Injury: A Uniform Data System for Medical Rehabilitation Investigation

ObjectivesTo examine regional differences in rehabilitation outcomes among adult patients with moderate-to-severe traumatic brain injury (TBI) who received care at an inpatient rehabilitation facility (IRF). DesignWe conducted a secondary analysis of a large, multi-center dataset from the Uniform Data System for Medical Rehabilitation. SettingMore than 70% of all IRFs in the United States. ParticipantsAdult TBI patients (N=175,358) aged 18 years or older who were admitted and discharged from an IRF in the United States between 2004 and 2014. Qualifying etiology included traumatic brain dysfunction Impairment Group codes 02.21 (traumatic, open injury) and 02.22 (traumatic, closed injury). InterventionsNot applicable. Main Outcome MeasuresDischarge functional status (total, cognitive, motor), length of stay, and discharge to home. ResultsPatient and clinical characteristics varied significantly by geographic location, as did median functional status, length of stay, and percentage of patients discharged home. The region where IRF care was received, race and ethnicity, age, occurrence of 1 or more falls during the IRF stay, case mix group, and insurance status were associated with discharge functional status, length of stay, and discharge to home. ConclusionsOur findings provide evidence of geographic differences in outcomes and potential disparities in care of TBI patients who received IRF care. More research is needed to identify TBI patients at risk for poor discharge outcomes to inform development and testing of interventions to reduce disparities in outcomes for these patients.

Association Between Comorbid Psychiatric Disorders and Hospital Resource Use in Physically Ill Pediatric Inpatients: A Case-Matched Analysis

To understand differences in hospital length of stay and costs associated with the presence of a comorbid psychiatric disorder among physically ill inpatients within a publicly funded pediatric hospital. This was a retrospective observational design using administrative data on physically ill inpatients 2 to 18 years old who were admitted over a 5-year period (n= 54,316 admissions). Records with (n= 4,953) and without (n= 49,363) documented comorbid psychiatric disorder were compared for differences in baseline characteristics. To optimize the balance of measured covariates, individuals with comorbid psychiatric disorders were matched on propensity score, case mix group, and Elixhauser comorbidities, resulting in 4,371 pairs of inpatients with and without a comorbid psychiatric disorder. Differences in length of stay and total hospital costs were assessed using generalized estimating equation models on matched patients. Unmatched analyses demonstrated that inpatient admissions with comorbid psychiatric disorders were associated with higher occurrence of previous hospitalizations (69.2% versus 55.0%), unscheduled admissions (66.9% versus 60.9%), medical admissions (75.6% versus 52.7%), urgent admissions (62.5% versus 56.2%), and Elixhauser comorbidities (69.0% versus 39.0%), with standardized differences > |0.1|. Matched analyses demonstrated a 9.6% longer length of stay (95% CI= 5.7-13.7; p< .001) and 9.6% higher costs per admission (95% CI= 5.9-13.4; p< .001) in inpatients with comorbid psychiatric disorders compared to those without. The complexity of inpatients with a comorbid psychiatric disorder, in conjunction with the approximate 10% increase in hospital resource use, highlights the need for innovative models of clinical care and research directed at improving patient outcomes and reducing hospital costs.

INCIDENCE AND ROOT CAUSE OF UPCODING IN THE IMPLEMENTATION OF SOCIAL HEALTH INSURANCE IN RURAL PROVINCE HOSPITAL IN INDONESIA

Upcoding is one of important indicators of moral hazard and fraud in Social Health Insurance scheme. However, there seems to be little evidence about incidence of upcoding and how upcoding occurs in hospital, especially in rural province hospital. The objective of this study is to determine incidence and root cause of upcoding in the implementation of Social Health Insurance in Rural Province Hospital in Indonesia. The data used in this study were both qualitative and quantitative data (mixed method). Three hundred and sixty (360) inpatient medical records from six rural province hospitals were examined in this study. Diagnosis and procedure codes recorded in these medical records were re-coded by an independent senior coder (ISC). Codes from hospitals’ coders and codes from ISC were then re-grouped using INA-CBG casemix grouper to determine the casemix groups and the hospital tariffs. If the hospital tariff obtained by hospital coder is higher than that obtained by ISC, it is considered as upcoding. This qualitative study was conducted using Focus Group Discussion (FGD) and in-depth interviews in hospitals located in a rural province of Indonesia. In depth interview was held for two hospital directors and two officers from the Social Security Administrator (Indonesia: BadanPenyelenggaraJaminanSosial/BPJS), an agent that manages the Statutory Health Insurance (SHI). Six clinicians and six coders attended the FGD. We asked open-ended questions about their perceptions on upcoding in hospitals. The interviews were recorded and transcribed verbatim. The transcripts were then thematically analyzed. Upcoding cases were found in 11.9% (43/360) medical records. Upcoding cases were dominated by Deliveries Group 2.8% (10/360) and Female reproductive system Groups 1.7% (6/360). The potential loss of income due to upcoding was IDR 154.626.000 or 9% of hospital revenue. Appointment of non-medical doctors as internal verifiers, lack of clear coding guidelines, lack of training for doctors and coders, and poor coordination between hospital and BPJS to resolve coding disagreement were root causes of upcoding in hospital. Policies to prevent and manage upcoding should be urgently developed and implemented in the Statutory Health Insurance (SHI) program in Indonesia especially to prepare upcoding guidelines, enhance medical coding trainingregularly, increase number of coders and verification staff from medical background, and strengthen coordination for coding problem solving in hospital.

Sex Differences in Long-Term Mortality and Functional Outcome After Rehabilitation in Patients With Severe Stroke.

Objective: We sought to determine sex differences in outcomes in patients with severe stroke who had been admitted to inpatient rehabilitation.Methods: We studied 1,316 patients aged 18 to 99 (mean 72) classified as case-mix groups 0108, 0109, and 0110 of the Medicare case-mix classification system. These groups encompass the most severe strokes. Three outcomes were analyzed: (1) 3-year mortality from admission to rehabilitation; (2) combined outcome of transfer to acute care or death within 90 days from admission to rehabilitation; (3) functional outcome, including proportional recovery in motor functioning and good functional outcome as defined by achievement of a Functional Independence Measure (FIM)-motor score ≥65 points at discharge. Multivariable regression analyses were used to assess sex-difference in each outcome between women and men. The covariates examined included age, marital status, comorbidities, time from stroke onset to rehabilitation admission <30 days, ischemic stroke, dysphagia, neglect, motor FIM score at admission, and cognitive FIM score at admission.Results: Kaplan-Meier estimated 3-year mortality rate was 20.7% in women and 22.0% in men. The crude hazard ratio (HR) of death for women compared with men was 0.94 (95% CI 0.74–1.20). After adjustment for significant covariates, the HR of 3-year mortality was 0.73 (95% CIs 0.56–0.96; p = 0.025). Comorbidity, including diabetes, anemia, coronary artery disease, atrial fibrillation, and chronic obstructive pulmonary disease, significantly increased mortality risk by 49–88%. The incidence of the combined outcome was 8.3% in women and 8.4% in men. The crude HR of the combined end-point for women compared with men was 1.05 (95% CI 0.72–1.53). After adjustment for significant covariates, the HR was 0.95 (95% CIs 0.65–1.40; p = 0.810). Likewise, no significant difference in proportional recovery or in the rate of achievement of a good functional outcome between women and men was observed.Conclusion: Among patients admitted to inpatient rehabilitation after severe stroke, women and men had comparable crude mortality rates at 3 years. After multivariable adjustment, however, women had lower mortality risk. No sex-differences in the risk of being transferred to acute care or dying within 90 days from admission to rehabilitation or in responsiveness to rehabilitation were observed.

Thirty-day readmission after medical-surgical hospitalization for people who experience imprisonment in Ontario, Canada: A retrospective cohort study.

We aimed to compare 30-day readmission after medical-surgical hospitalization for people who experience imprisonment and matched people in the general population in Ontario, Canada. We used linked population-based correctional and health administrative data. Of people released from Ontario prisons in 2010, we identified those with at least one medical or surgical hospitalization between 2005 and 2015 while they were in prison or within 6 months after release. For those with multiple eligible hospitalizations, we randomly selected one hospitalization. We stratified people by whether they were in prison or recently released from prison at the time of hospital discharge. We matched each person with a person in the general population based on age, sex, hospitalization case mix group, and hospital discharge year. Our primary outcome was 30-day hospital readmission. We included 262 hospitalizations for people in prison and 1,268 hospitalizations for people recently released from prison. Readmission rates were 7.7% (95%CI 4.4-10.9) for people in prison and 6.9% (95%CI 5.5-8.3) for people recently released from prison. Compared with matched people in the general population, the unadjusted HR was 0.72 (95%CI 0.41-1.27) for people in prison and 0.78 (95%CI 0.60-1.02) for people recently released from prison. Adjusted for baseline morbidity and social status, hospitalization characteristics, and post-discharge health care use, the HR for 30-day readmission was 0.74 (95%CI 0.40-1.37) for people in prison and 0.48 (95%CI 0.36-0.63) for people recently released from prison. In conclusion, people recently released from prison had relatively low rates of readmission. Research is needed to elucidate reasons for lower readmission to ensure care quality and access.

Association Between Malnutrition and Outcomes in Patients With Severe Ischemic Stroke Undergoing Rehabilitation

ObjectiveTo investigate the incremental prognostic significance of malnutrition in patients with severe poststroke disability. DesignRetrospective cohort study. The patients were recruited from 3 specialized inpatient rehabilitation facilities. Nutritional status was assessed using the Prognostic Nutritional Index (PNI), which is calculated from serum albumin and total lymphocyte count. Scores >38 points reflect normal nutrition status, scores of 35-38 indicate moderate malnutrition, and scores <35 indicate severe malnutrition. The association of PNI categories with outcomes was assessed using multivariable regression analyses. SettingInpatient rehabilitation facility. ParticipantsPatients (N=668) with ischemic stroke admitted to inpatient rehabilitation within 90 days from stroke occurrence and classified as Case-Mix Groups 0108, 0109, and 0110 of the current Medicare case-mix classification system. InterventionsNot applicable. Main Outcome MeasuresThree outcomes were examined: (1) the combined outcome of transfer to acute care and death within 90 days from admission to rehabilitation; (2) 2-year mortality; and (3) FIM motor effectiveness, calculated as (FIM motor change/maximum FIM motor−admission FIM motor score)×100. ResultsOverall, the median time to rehabilitation admission was 18 days (range, 12-26 days). The prevalence of moderate and severe malnutrition was 12.7% and 11.5%, respectively. Ninety-one patients (13.6%) experienced the combined outcome. After adjusting for independent predictors including sex, atrial fibrillation, dysphagia, FIM cognitive score, and hemoglobin levels, neither moderate (P=.280) nor severe malnutrition (P=.482) were associated with the combined outcome. Similar results were observed when looking at 2-year mortality. Overall, FIM motor effectiveness was 30%±24%. After adjusting for independent predictors, severe malnutrition (β coefficient −0.458±0.216; P=.034) was associated with FIM motor effectiveness. ConclusionsApproximately 1 in every 9 patients presented severe malnutrition. On top of the independent predictors, severe malnutrition did not provide additional prognostic information concerning risk of the combined outcome or 2-year mortality. Conversely, severe malnutrition was associated with poorer functional outcome as expressed by FIM motor effectiveness.

Outcomes of aortic aneurysm surgery in England: a nationwide cohort study using hospital admissions data from 2002 to 2015

BackgroundThe United Kingdom aortic aneurysms (AA) services have undergone reconfiguration to improve outcomes. The National Health Service collects data on all hospital admissions in England. The complex administrative datasets generated have the potential to be used to monitor activity and outcomes, however, there are challenges in using these data as they are primarily collected for administrative purposes. The aim of this study was to develop standardised algorithms with the support of a clinical consensus group to identify all AA activity, classify the AA management into clinically meaningful case mix groups and define outcome measures that could be used to compare outcomes among AA service providers.MethodsIn-patient data about aortic aneurysm (AA) admissions from the 2002/03 to 2014/15 were acquired. A stepwise approach, with input from a clinical consensus group, was used to identify relevant cases. The data is primarily coded into episodes, these were amalgamated to identify admissions; admissions were linked to understand patient pathways and index admissions. Cases were then divided into case-mix groups based upon examination of individually sampled and aggregate data. Consistent measures of outcome were developed, including length of stay, complications within the index admission, post-operative mortality and re-admission.ResultsSeveral issues were identified in the dataset including potential conflict in identifying emergency and elective cases and potential confusion if an inappropriate admission definition is used. Ninety six thousand seven hundred thirty-five patients were identified using the algorithms developed in this study to extract AA cases from Hospital episode statistics. From 2002 to 2015, 83,968 patients (87% of all cases identified) underwent repair for AA and 12,767 patients (13% of all cases identified) died in hospital without any AA repair. Six thousand three hundred twenty-nine patients (7.5%) had repair for complex AA and 77,639 (92.5%) had repair for infra-renal AA.ConclusionThe proposed methods define homogeneous clinical groups and outcomes by combining administrative codes in the data. These methodologically robust methods can help examine outcomes associated with previous and current service provisions and aid future reconfiguration of aortic aneurysm surgery services.