Case-mix System Research Articles

International Incidence and Outcomes of Biliary Atresia

International trends in incidence and outcomes of biliary atresia (BA) are controversial and a wide range of estimates have been reported worldwide. We reviewed the population-based literature to assess international variation of BA incidence and outcomes, and to assess the evidence for seasonal variation in incidence, centralization of Kasai hepatoportoenterostomy, and newborn screening. We conducted a systematic review (registration number CRD42011001441) of observational or interventional research within MEDLINE, EMBASE, and the Cochrane Database, which reported incidence, prevalence, or outcomes of infants with BA. Population-based studies, defined by inclusion of an entire population or representative sample, were included. Outcomes included overall survival, native liver survival (NLS), and time to Kasai hepatoportoenterostomy. Single- or multicenter studies were excluded unless those centers captured all potential patients within a jurisdiction. Two independent data extractors reviewed the abstracts and articles. A total of 40 studies were included following review of 3128 references. A wide range of incidence was reported internationally. Ten-year overall survival ranged from 66.7% to 89%. NLS ranged from 20.3% to 75.8% at 1 to 3 years and 24% to 52.8% at 10 years. Earlier age at Kasai was a predictor of improved NLS. Seasonality was reported in 11 studies, and 3 reported an increased incidence during the months of August to March. The evidence for centralization of Kasai to high-volume centers is promising but does not account for all case-mix, provider, or health system factors involved in volume-outcome relations. Stool color card screening resulted in earlier Kasai and improved NLS in Taiwan. Large, international studies could help fill the gaps in knowledge identified by this review.

Treatment costs of acute myocardial infarction in the Netherlands

This study aimed to calculate the treatment costs of acute myocardial infarction (AMI) in the Netherlands for 2012. Also, the degree of association between treatment costs of AMI and some patient and hospital characteristics was examined. For this retrospective cost analysis, patients were drawn from the database of the Diagnosis Treatment Combination (Diagnose Behandeling Combinatie, DBC) casemix system, which contains data on the resource use of all hospitalisations in the Netherlands. All costs were based on Euro 2012 cost data. The analysis was based on data of 25,657 patients. Mean treatment costs were estimated at <euro> 5021, with significant cost increases for patients with percutaneous coronary intervention (PCI) treatment. ST-segment elevation myocardial infarction (STEMI) patients receiving thrombolysis incurred the lowest (<euro> 4286), while non-STEMI patients receiving PCI the highest costs (<euro> 6060). Length of stay and hospital type were strong predictors of treatment costs. This study is the most extensive cost assessment of the treatment costs of AMI in the Netherlands thus far. Our results may be used as input for health-economic models and economic evaluations to support the decision making of registration, reimbursement and pricing of interventions in healthcare.

An evaluation of data quality in Canada’s Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011

BackgroundEvidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15 years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally.MethodsData from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time.ResultsData quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC.ConclusionsThe CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations.

Distance to hospital and socioeconomic status influence secondary health care use

Objective. The aim of this study was to investigate how distance to hospital and socioeconomic status (SES) influence the use of secondary health care (SHC) when taking comorbidity into account. Design and setting. A register-based study in Östergötland County. Subjects. The adult population of Östergötland County. Main outcome measures. Odds of SHC use in the population and rates of SHC use by patients were studied after taking into account comorbidity level assigned using the Adjusted Clinical Groups (ACG) Case-Mix System. The baseline for analysis of SES was individuals with the lowest education level (level 1) and the lowest income (1st quartile). Results. The study showed both positive and negative association between SES and use of SHC. The risk of incurring SHC costs was 12% higher for individuals with education level 1. Individuals with income in the 2nd quartile had a 4% higher risk of incurring SHC costs but a 17% lower risk of emergency department visits. Individuals with income in the 4th quartile had 9% lower risk of hospitalization. The risk of using SHC services for the population was not associated with distance to hospital. Patients living over 40 km from hospital and patients with higher SES had lower use of SHC services. Conclusions. It was found that distance to hospital and SES influence SHC use after adjusting for comorbidity level, age, and gender. These results suggest that GPs and health care managers should pay a higher degree of attention to this when planning primary care services in order to minimize the potentially redundant use of SHC.

Increased registration of hypertension and cancer diagnoses after the introduction of a new reimbursement system

Objective. To investigate the impact on ICD coding behaviour of a new case-mix reimbursement system based on coded patient diagnoses. The main hypothesis was that after the introduction of the new system the coding of chronic diseases like hypertension and cancer would increase and the variance in propensity for coding would decrease on both physician and health care centre (HCC) levels. Design. Cross-sectional multilevel logistic regression analyses were performed in periods covering the time before and after the introduction of the new reimbursement system. Setting. Skaraborg primary care, Sweden. Subjects. All patients (n = 76 546 to 79 826) 50 years of age and older visiting 468 to 627 physicians at the 22 public HCCs in five consecutive time periods of one year each. Main outcome measures. Registered codes for hypertension and cancer diseases in Skaraborg primary care database (SPCD). Results. After the introduction of the new reimbursement system the adjusted prevalence of hypertension and cancer in SPCD increased from 17.4% to 32.2% and from 0.79% to 2.32%, respectively, probably partly due to an increased diagnosis coding of indirect patient contacts. The total variance in the propensity for coding declined simultaneously at the physician level for both diagnosis groups. Conclusions. Changes in the healthcare reimbursement system may directly influence the contents of a research database that retrieves data from clinical practice. This should be taken into account when using such a database for research purposes, and the data should be validated for each diagnosis.

Developing sub-acute, non-acute and special groups in the universal grouper

The use of Casemix system as providers’ reimbursement method under social health insurance schemes has spread beyond high-income countries. Over the last decade many low and middle-income countries (LMIC) have started to implement Casemix system to replace the conventional yet inefficient fee-for-service as provider payment mechanism. UNU-IIGH launched an international grouper called UNU-CBG in 2010 to support the implementation of Casemix system in LMIC. To date, UNU-CBG has been introduced in 12 countries in different phases of implementation process. UNU-CBG was designed to function as an international grouper that can be customized and adapted to suit the local needs and norms of each country. However inability to provide robust groupings for sub-acute and chronic conditions is a major limitation in the use of Casemix system in these countries. Sub-acute and chronic diseases that account for more than two thirds of disease burden in LMIC should be categorized in mutually exclusive groups if the reimbursement were to be made using Casemix system. Researchers in UNU-IIGH and International Casemix and Clinical Coding Centre of UKM have been working very hard for the past two years to upgrade the capacity of UNU-CBG grouper to classify sub-acute and chronic cases into Casemix group. Additional variables included in the new grouping algorithm are extended length of stay, costly prostheses, drugs, procedures, investigations and scores of Activity of Daily Living. The new version of UNU-CBG launched during this conference provides an opportunity for social health insurance managers in LMIC to use Casemix system as a total solution for provider payment method.

The impact of Casemix system on quality of patient care in a Class B hospital in west Sumatera Province, Indonesia

Background Health spending in Indonesia is on the increase every year due to a number of factors including change in pattern of diseases towards chronic and non-communicable conditions, priority on curative care rather than preventive services, use of new technology in health services and use of fee-for-service for provider payment. Raise in health care cost can have negative impact on accessibility of health service by the poor communities. In Indonesia, the Ministry of Health has launched a special program to ensure that the poor have access to health care services. One of the most important programs is JAMKESMAS, which is a special health financing scheme for the poor funded by taxation. The implementation of Casemix in Indonesia is based on a special law (Undang-undang No.40) and Minister of Health decree (SK Menkes No. 1663/MENKES/SK/XII/2005). Casemix was implemented as a pilot project involving 14 hospitals in 2005. However in 2008, the use of Casemix was extended to cover all hospitals in Indonesia. Hospitals are reimbursed on locally customized Casemix system called INA-CBG, which is based on UNU-CBG case-mix grouper. In the first phase of Casemix implementation, the system was used to develop hospital tariff for prospective payment with the objective of enhancing service efficiency. However it is widely known that Casemix system is also a powerful tool to enhance quality of care. A number of challenges were identified in the early part of case-mix implementation in Indonesia. These include lack of basic data for Casemix, poor documentation of diagnosis and procedures, and ineligible handwriting of doctors in the medical records. Presently, there is no study carried out in Indonesia to assess the impact of case-mix system implementation on quality of patient care.

Casemix system in Nordic countries

The five Nordic countries are characterized by stable political systems based on consensus and interactive contracts between the populations and their governments. There has been a prosperous development through more than half a century, which also has resulted in a model of ’good health care for all’. However from late part of 1980s and during the 1990s it was realised that the cost of health care escalated beyond what was considered to be sustainable. The concept of Casemix was introduced to all the Nordic countries over a few years in the 1990s, but the implementation of Casemix systems differed considerably between the five countries. From 1966 the NOMESCO (Nordic Medico-Statistical Committee) presented statistical analyses to facilitate comparisons between the Nordic countries, and based on experiences from the NOMESCO collaboration, the Nordic Centre for Classifications in Health Care was established as a WHO Collaborating Centre in 1987. The Centre has been a common arena to develop and manage health classifications (NCSP, NCECI) and the NordDRG Casemix grouper, as well as support to the WHO ICD-10 update process with views from the Nordic medical profession. At the presentation elaboration on the historical development will be given with focus on the various paths of development, which the Casemix concept took in each of the Nordic countries. The differences in governance (state engagement or not) are discussed, as is the need for knowledge and education. Innovation and future trends will be mentioned.

Development of package payment based on UNU-CBGs Casemix system for provider payment in Aceh Health Insurance, Indonesia

Background The Aceh Health Insurance (JKA) has been established since June 1, 2010. Presently, the provincial Government of Aceh faces difficulty in getting adequate budget to fund JKA program that tends to increase every year. In the year 2010, the second year of JKA implementation, the government was only able to allocate Rp. 382 billion from the total requirement of Rp. 482 billion. The figure will possibly continue to increase next year because of the increase in the overall hospital tariff of adjustments where there was an increase over 50%. In addition, there were complaints that quality of care is not optimum. The fee for service reimbursement system in JKA is one of the reasons for increase in cost of JKA. The main purposes of this study are to develop and implement the Casemix system as a provider payment mechanism and to assess its feasibilities to improve the performance of JKA program.

Evaluation of introduction to UNU-Casemix grouper &amp; IT in Casemix system workshop for health staff in Indonesia

Implementation of Casemix system needs a well-organized and computerized system with well-trained and oriented staff, otherwise the system will fail. Improving knowledge and understanding of the funding system among staff and managers in hospitals and health systems can provide the groundwork for service improvements. The aim of this study was to evaluate the effectiveness of Introduction to UNU-Casemix Grouper & IT in Casemix System workshop which was conducted in Indonesia.

Implementation of Casemix system in Hospital Universiti Sains Malaysia by using UNU-CBG grouper: is it feasible to support apex programme?

Background The framework of “Accelerated Programme for Excellence” (APEX), modeled on the German Universities Excellence Initiative, is profoundly important and decisive initiative for Malaysian higher education. The selection of USM under APEX initiative is based on the university’s state of readiness, preparedness and transformation plan for change that focused on diagnostics, medical biotechnology, waste management, pharmaceuticals, nano-technology, membrane technology and vaccines. Becoming an APEX University, HUSM indeed is committed to achieve certain goals in their functions as teaching and referral hospital in the east cost of Peninsular Malaysia. One of the priority goals is to ensure that resources and allocation for each department within hospital is sufficiently distributed to ensure health care delivery is efficient and maintain at high quality to the patient. Selection of UNU-CBG Grouper is justified from the universal and dynamic functions of this Grouper that able to cater for various severity levels and able to capture an Acute (in-patient and outpatient), Sub-Acute (moderately complex cases) as well as Chronic Case (long stay cases) patients.

Casemix system for the elderly persons in Japan

Background Casemix classification systems for post acute care have been developed in several countries. The paradigm of each system is different depending on service and target population and the intension of the system itself. Japanese classification system is more suitable for long-term nursing care for elderly person. In contrast, RUGs system used in the US considers rehabilitation and medical service highly in their hierarchical system suitable as a sub-acute classification system.

Is the international classification of healthcare procedures (ICHI) a critical point for the implementation of an international Casemix grouper?

Most of developed countries have kept on maintaining, updating and modifying their own coding systems for procedures, as well as national adaptations of ICD, in order to manage and to fund their health care delivery. The most significant efforts were done in Australia with ACHI (Australian Classification of Health Interventions) or ICD10 AM, in Canada with the Canadian Classification of Health Interventions (CCI) developed by the Canadian Institute for Health Information (CIHI) and in France with CCAM (Classification Commune des Actes Medicaux). For some decades several broad pre-coordinated or compositional systems have been proposed to users targeting different goals. The most well known are the UMLS (Unified Medical Language System), LOINC for clinical laboratories, DICOM SDM for imaging, SNOMED, Convergent Medical Terminology (CMT). Since 2010 WHO FIC has developed ICHI to describe health intervention defined as an activity performed for, with or on behalf of a client(s) whose purpose is to improve individual or population health, to alter or diagnose the course of a health condition or to improve functioning. This definition includes interventions that apply to more than one client or to a population group. As a consequence the prospective international classification will include interventions across the whole health system. It would include interventions provided by all types of providers: doctors, dentists, nurses, allied and community health workers, traditional medicine providers and public health practitioners. The aims of this international classification are to 1) describe and compare the provision and effectiveness of health interventions at the local, national or international level. 2) provide a classification of appropriate scope and detail to which countries may align their more finely grained national or specialty classifications. 3) ensure that a classification is available that can be used without adaptation in countries which do not wish to further refine the classification. 4) take into account that interventions include elements of ‘western’ and ‘traditional’ medicine. ICHI is now a procedures classification with the level of granularity of ICD-9-CM Volume 3. It is an incentive able to harmonize between the national classifications of health interventions. Such Countries interested in comparability of data including Casemix systems analyzed by an international Casemix grouper should modify their existing systems partially to be compliant with the framework but are not mandated to change the full terminology they use. For countries without an interventions classification and namely developing countries it can be used directly. ICHI is providing the opportunity to compare the performance of different health care systems using an international Casemix grouper.

Using alternative programming algorithms and techniques for optimizing performance of the Casemix software

Casemix system is a patient classification system that classifies patients into predefined groups based on the patient level data. Because of the immense variation of the individual patient level data it is very tedious to do this Casemix group allocation manually, instead Casemix classification software with a predefined logic is used. UNU-IIGH has developed Casemix logic, and an application for easy usage by end users. As part of continuous quality improvement, it was to upgrade the Casemix software for improved data processing.

Integrating Casemix system in to the Philippine social health insurance

The Philippine Health Insurance Corporation (PhilHealth) is a government owned and controlled corporation, established in 1995 and tasked to implement the National Health Insurance Program. Since its inception, PhilHealth has utilized the fee-for-service scheme for majority of inpatient benefits and case payment for selected, mostly outpatient benefits. In 2010, the country elected a new president and Universal Health Care was declared a national agenda. The challenge for PhilHealth was not only to ensure 100% coverage but provide true financial risk protection. One of the identified key strategies was to shift to a new provider payment mechanism that will foster patient empowerment through clear and predictable financial support. In Sept 2011, PhilHealth rolled out the first 23 medical and surgical case rates which accounts for 45% of all cases being reimbursed by PhilHealth the previous years. Rates were determined by assigning weights to previously obtained tariff rates, contracting rates for public and private hospitals and average value per claim for the preceding years. The highest computed rates were identified and used. Along with this, a zero co-payment policy or No Balance Billing policy was instituted. After almost 8 months of implementation, case payment scheme is proving to be the only solution for PhilHealth to ensure member empowerment, cost containment and claims processing efficiency. However, the problem still lies in government not being able to provide the necessary medicines and services that is already included in the case payment package. Despite these challenges, 29 medical and 32 surgical illnesses more will be paid as case rates. This will then account for 85% of cases being reimbursed by PhilHealth until a time that these case rates will be converted to full case mix. The change in payment provider mechanism entails a big paradigm shift for the whole health system. Reform interventions inside the corporation are being done that will truly inform, empower and guide its members. Expansion of benefit packages has started. Information technology infrastructure is in full swing and new engagement processes with providers are being adapted. In the end, universal health care can be achieved by re-awakening the spirit of solidarity among Filipinos, which is the very essence of the National Health Insurance Program.

Monitoring the prevalence of chronic conditions: which data should we use?

BackgroundChronic diseases are an increasing threat to people’s health and to the sustainability of health organisations. Despite the need for routine monitoring systems to assess the impact of chronicity in the population and its evolution over time, currently no single source of information has been identified as suitable for this purpose. Our objective was to describe the prevalence of various chronic conditions estimated using routine data recorded by health professionals: diagnoses on hospital discharge abstracts, and primary care prescriptions and diagnoses.MethodsThe ICD-9-CM codes for diagnoses and Anatomical Therapeutic Chemical (ATC) codes for prescriptions were collected for all patients in the Basque Country over 14 years of age (n=1,964,337) for a 12-month period. We employed a range of different inputs: hospital diagnoses, primary care diagnoses, primary care prescriptions and combinations thereof. Data were collapsed into the morbidity groups specified by the Johns Hopkins Adjusted Clinical Groups (ACGs) Case-Mix System. We estimated the prevalence of 12 chronic conditions, comparing the results obtained using the different data sources with each other and also with those of the Basque Health Interview Survey (ESCAV). Using the different combinations of inputs, Standardized Morbidity Ratios (SMRs) for the considered diseases were calculated for the list of patients of each general practitioner. The variances of the SMRs were used as a measure of the dispersion of the data and were compared using the Brown-Forsythe test.ResultsThe prevalences calculated using prescription data were higher than those obtained from diagnoses and those from the ESCAV, with two exceptions: malignant neoplasm and migraine. The variances of the SMRs obtained from the combination of all the data sources (hospital diagnoses, and primary care prescriptions and diagnoses) were significantly lower than those using only diagnoses.ConclusionsThe estimated prevalence of chronic diseases varies considerably depending of the source(s) of information used. Given that administrative databases compile data registered for other purposes, the estimations obtained must be considered with caution. In a context of increasingly widespread computerisation of patient medical records, the complementary use of a range of sources may be a feasible option for the routine monitoring of the prevalence of chronic diseases.

Program-based case-mix classification system vs. per-diem based system in post-acute care: Which model for financing rehabilitation?

Program-based case-mix classification system vs. per-diem based system in post-acute care: Which model for financing rehabilitation?

The Tariff – traps for the unwary

The Tariff – traps for the unwary

UPDATE OF THE DUTCH MANUAL FOR COSTING IN ECONOMIC EVALUATIONS

In 2000, the first "Dutch Manual for Costing: METHODS and Reference Prices for Economic Evaluations in Healthcare" was published, followed by an updated version in 2004. The purpose of the Manual is to facilitate the implementation and assessment of costing studies in economic evaluations. New developments necessitated the publication of a thoroughly updated version of the Manual in 2010. The present study aims to describe the main changes of the 2010 Manual compared with earlier editions of the Manual. New and updated topics of the Manual were identified. The recommendations of the Manual were compared with the health economic guidelines of other countries, eliciting strengths and limitations of alternative methods. New topics in the Manual concern medical costs in life-years gained, the database of the Diagnosis Treatment Combination (DBC) casemix System, reference prices for the mental healthcare sector and the costs borne by informal care-givers. Updated topics relate to the friction cost method, discounting future effects and options for transferring cost results from international studies to the Dutch situation. The Action Plan is quite similar to many health economic guidelines in healthcare. However, the recommendations on particular aspects may differ between national guidelines in some respects. Although the Manual may serve as an example to countries intending to develop a manual of this kind, it should always be kept in mind that preferred methods predominantly depend on a country's specific context.

Quantifying morbidity burdens and medical utilization of children with intellectual disabilities in Taiwan: A nationwide study using the ACG case-mix adjustment system

The purpose of this study was to quantify morbidity burdens of children with intellectual disability (ID) and to examine its association with total medical utilization and expenditure on a national basis in Taiwan. People under 18 years of age that had been continuously enrolled in the National Health Insurance (NHI) between year 2008 and 2010 were selected from one million randomly-sampled NHI beneficiaries. The Johns Hopkins Adjusted Clinical Group (ACG) System was applied to evaluate an individual's morbidity burden using 2008-2010 claims data, including age, sex, diagnosis, pharmacy, ambulatory, and inpatient utilization and expenditure (in New Taiwan Dollars, NTDs). The ID prevalence rate was 0.69% for people aged under 18. People with ID could be assigned to 20 mutually exclusive ACGs and to five simplified morbidity categories: healthy (0.1%), low (1.5%), moderate (31.9%), high (44.0%), and very high (22.4%). People with ID had more per capita visits (108.4 vs. 51.5, p<0.001), hospital admission (27.7% vs. 13.1%, p<0.001), pharmacy (NTD 21,069 vs. 4983, p<0.001) and total expenditure (NTD 144,962 vs. 29,764, p<0.001) than those without ID over 3 years. Those who assigned to the high-morbid categories cost more in ambulatory and inpatient services than those with low to moderate morbidities. In conclusion, the morbidity burdens of people with ID can be quantified by the ACG System based on readily available data. Regularly evaluating morbidity burdens and medical utilization has particular relevance for planning high-quality and efficient care. People's disabilities and comorbid illnesses shall be treated by integrated multidisciplinary teams.