Diagnosis-related Group Reimbursement System Research Articles

Enlightening Nursing Care: A Protocol for a Multicenter Observational Study Measuring Nursing Work in Hospital Settings.

Background: Rising costs and demands for improved quality of care present complex challenges for existing healthcare systems. The strain on healthcare resources is exacerbated by the increasing complexity of patient conditions. The Diagnosis-Related Group (DRG) system classifies inpatients according to clinical and treatment criteria, controls healthcare expenditures, and ensures the sustainability of procedures. The cost of nursing care is included in the DRG system in the same way as other fixed costs of hospital care, but the amount of nursing care provided for the same DRG can vary widely. This study, which is based on this protocol, will aim to assess the variability of nursing costs within and across DRGs and to measure how much variability in nursing care is explained by DRGs by comparing nursing care delivery in acute care hospitals with the DRG reimbursement system in Italy. It is necessary to develop a specific protocol to ensure systematic and consistent data collection at the national level. Methods: A multicenter retrospective cross-sectional study will be conducted. A random sample of five public Italian hospitals will be enrolled. Patients included in medical or surgical DRGs, hospitalized and discharged in 2022 will be included. Data will be collected retrospectively from two sources: hospital discharge records and nursing records. Inferential statistics will be used to assess the variability of nursing time and costs across hospitals and DRGs. Nursing costs will be determined by several factors, including time spent on nursing activities and the hourly wages of nursing staff. The time needed to complete each activity will be estimated by a convenience sample of nurses from the hospitals included in this study. The annual salary of nurses will be used to calculate the nursing cost per minute, multipled by the amount of time spent per each nursing activity. The cost per patient per day of hospitalization will be calculated. Conclusions: The results of this study will shed light on the variation in nursing care across different DRGs. This understanding will guide recommendations for optimizing healthcare resource allocation and enhancing the efficiency of the DRG system in Italy.

The New Diagnosis-Related Group Reimbursement System and Laboratory Test Quality in Korea: Analysis of External Quality Assessment Results.

Korea introduced a new diagnosis-related group (NDRG), which is a mixed-bundle reimbursement system. We evaluated the effects of NDRGs on laboratory test quality by analyzing data over three years (2016–2018) from the Korean Association of External Quality Assessment Service (KEQAS). A total of 42 NDRG-participating hospitals (CASE), 84 non-participating similar size-hospitals (CON-1), and 42 tertiary hospitals (CON-2) were included. We assumed the proportion of KEQAS results with a larger than 2 standard deviation index (SDI) to be a bad laboratory quality marker (BLQM). CASE BLQMs were lower than CON-1 BLQMs for more than 2 years in alkaline phosphatase (ALP), alanine aminotransferase (ALT), chloride, glucose, sodium, and total protein, and higher in creatinine. CASE BLQMs were higher than CON-2 BLQMs for more than 2 years in ALP, chloride, creatinine, glucose, lactate dehydrogenase (LDH), phosphorus, potassium, sodium, total calcium, total cholesterol, triglyceride, and uric acid. Mean SDIs for general chemistry tests were not significantly different depending on NDRG participation. However, the NDRG is currently a pilot program that compensates the amount of each institution’s reimbursement based on the fee-for-service system, and most participants were public hospitals. Thus, the effects of NDRGs on laboratory test quality should be re-evaluated after the NDRG program has stabilized and more private hospitals are participating.

An Evaluation of Diagnosis-Related Group (DRG) Implementation Focused on Cancer DRGs in Greek Public Hospitals.

ObjectivesThe main aims of this study were to evaluate the Greek version of the diagnosis-related group reimbursement system (KEN-DRG) and to compare the KEN-DRG prices with the average actual cost of each group of study cases. Along with other aspects, the differences between the KEN-DRG average length of stay (ALOS) and the actual ALOS was evaluated in selected cases.MethodsIn the first part of this study, the top-down costing approach was selected in order to break down the total operating costs of the hospital, by hospital department. The aim of this stage was identification of the total operating costs and the average cost per patient day for each Internal Medicine Department of the ‘Hippokration’ General Hospital of Athens during the period 2014–2015. The final cost drivers were identified using the concept of cluster-related incidents in the hospital. In a subsequent stage, the 13 most frequent cancer KEN-DRG prices charged by Internal Medicine Departments were selected as a sample for further data analysis.ResultsWith regard to the costing of the oncological KEN-DRG, the present study illustrates that a majority of the current reimbursement rates for oncological KEN-DRG codes are under-reimbursed, taking into account the actual costs of hospitalization for each group of cases. The results also reveal that the ALOS of the KEN-DRG does not reflect the actual ALOS in the sample of cases examined. In addition, under the scope of this study, two proposed models for the KEN-DRG price recalculation were developed, based on the average estimated cost of hospitalization for the sample incidents, which could improve the existing reimbursement system for Greek hospitals in the medium term.ConclusionsThe KEN-DRG payment system that was implemented in Greece for the first time in 2012 needs redesigning in terms of the true cost of hospital services and the actual cost of each patient’s treatment. With regard to the existing KEN-DRG reimbursement system, the current study suggested the use of a DRG price calculation model that consists of a relative weight factor and a base price, based on a real cost calculation process on an annual basis. Moreover, it should be stressed that the present study, as well as other related studies, make it possible to know the actual cost of hospitalization, and can contribute to the creation of a cost database over time at the level of hospitals or specific clinical departments.

Association of the Swiss Diagnosis-Related Group Reimbursement System With Length of Stay, Mortality, and Readmission Rates in Hospitalized Adult Patients

In 2012, hospital reimbursement in Switzerland changed from a fee-for-service per diem system to a diagnosis-related group (SwissDRG) system. Whether this change in reimbursement is associated with harmful implications for quality of care and patient outcomes remains unclear. To examine the association of the SwissDRG implementation with length of hospital stay (LOS), in-hospital mortality, and 30-day readmission rates in the overall adult inpatient population and stratified by 5 individual diagnoses. This cohort study used administrative data from the Swiss Federal Statistical Office to investigate medical hospitalizations in Switzerland from January 1, 2009, through December 31, 2015. All hospitalizations for adult medical inpatients were included in the main analysis. Patients who presented with 1 of the 5 common medical diagnoses were included in the subanalyses: community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, acute myocardial infarction, acute heart failure, and pulmonary embolism. An interrupted time series model was used to determine changes in time trends for risk-adjusted LOS, in-hospital mortality, and 30-day readmission after the implementation of SwissDRG in 2012. Analyses were performed from March 1, 2018, to June 30, 2018, and from November 1, 2018, to December 18, 2018. Monthly patient-level data for LOS, in-hospital mortality, and 30-day readmission rates. The sample included a total of 2 426 722 hospitalized adult patients. Of this total, 1 018 404 patients (41.9%; 531 226 [52.2%] male, median [interquartile range (IQR)] age of 69 [55-80] years) composed the before-SwissDRG period; 1 408 318 patients (58.0%; 730 228 [51.9%] male, median [IQR] age of 70 [56-81] years) composed the after-SwissDRG period. The overall LOS gradually decreased from unadjusted mean (SD) 8.0 (12.7) days in 2009 to 7.2 (17.3) days in 2015. This reduction in LOS, however, was not substantially greater with the implementation of SwissDRG in 2012 (risk-adjusted slope, -0.0166 days; 95% CI, -0.0223 to -0.0110 days), with an adjusted difference in slopes of 0.0000 days (95% CI, -0.0072 to 0.0072 days). Risk-adjusted all-cause in-hospital mortality declined from 4.9% in 2009 to 4.6% in 2015, with a substantially greater decline after implementation of SwissDRG (difference between monthly slopes before and after implementation, -0.0115%; 95% CI, -0.0190% to -0.0039%). In the same period, risk-adjusted 30-day readmission rates increased from 14.4% in 2009 to 15.0% in 2015, with a greater increase after SwissDRG implementation (change in monthly slope, 0.0339%; 95% CI, 0.0254%-0.0423%). Patients with acute myocardial infarction were found to have a substantially greater increase after SwissDRG implementation in 30-day readmission rates (adjusted difference in slopes, 0.1144%; 95% CI, 0.0617%-0.1671%). Among medical hospitalizations in Switzerland, SwissDRG implementation appeared to be associated with an increase in readmission rates and a decrease in in-hospital mortality but not with the gradual decrease in LOS observed in the historical control period.

Reimbursement of care for severe trauma under SwissDRG.

Treatment of patients with severe injuries is costly, with best results achieved in specialised care centres. However, diagnosis-related group (DRG)-based prospective payment systems have difficulties in depicting treatment costs for specialised care. We analysed reimbursement of care for severe trauma in the first 3 years after the introduction of the Swiss DRG reimbursement system (2012-2014). The study included all patients with solely basic insurance, hospital admission after 01.01.2011 and discharge in 2011 or 2012, who were admitted to the resuscitation room of the University Hospital of Zurich, aged ≥16 years and with an injury severity score (ISS) ≥16 (n = 364). Clinical, financial and administrative data were extracted from the electronic medical records. All cases were grouped into DRGs according to different SwissDRG versions. We considered results to be significant if p ≤0.002. The mean deficit decreased from 12 065 CHF under SwissDRG 1.0 (2012) to 2 902 CHF under SwissDRG 3.0 (2014). The main reason for the reduction of average deficits was a refinement of the DRG algorithm with a regrouping of 23 cases with an ISS ≥16 from MDC 01 to DRGs within MDC21A. Predictors of an increased total loss per case could be identified: for example, high total number of surgical interventions, surgeries on multiple anatomical regions or operations on the pelvis (p ≤0.002). Psychiatric diagnoses in general were also significant predictors of deficit per case (p<0.001). The reimbursement for care of severely injured patients needs further improvement. Cost neutral treatment was not possible under the first three versions of SwissDRG.

The possible impact of the German DRGs reimbursement system on end-of-life decision making in a surgical intensive care unit.

More than 70 % of critically ill patients die in intensive care units (ICUs) after treatment is reduced. End-of-life decision making in the ICU is a grey area that varies in practice, and there are potential economic consequences of over- and under-treatment. The aim of this study was to describe the end-of-life decisions of critically ill patients in a surgical ICU in Germany and to identify how financial incentives may influence decision making. Data on the admission diagnosis, end-of-life decision making and cause of death were obtained for 69 critically ill patients who died in the ICU (Hospital of Bayreuth, Germany) in 2009. A cost-revenue analysis was conducted on the 46 patients who did not die within 3 days of ICU admission. Because we lacked real data on costs, our analysis was based on the average cost for each diagnosis-related group (DRG) from the Institute for the Hospital Remuneration System (InEK). Hospital revenues based on the DRG were considered. Subsequently, we compared the estimated financial impact of earlier and later decisions to withdraw or withhold futile therapy. In this study, we found that end-of-life decision making was poorly documented. Only 11 % of patients had a valid power of attorney and advanced directives, and therapy with presumed consent was performed in 43 % of all cases. From long-stay patients, therapy was withdrawn for 37 % of patients and withheld from 26 % of patients, and 37 % of the patients died receiving maximal therapy. Almost 72 % of DRG-related reimbursements were dependent on ventilation hours. The average total cost estimate (according to InEK) for the 46 long-stay patients was 1,201,000 <euro>. The revenues without additional remuneration were 1,358,000 <euro>, and the total estimated profit was approximately 157,000 <euro>. Only 10 cases were assumed to be non-profitable. In cases where the decision to withdraw or withhold therapy could have occurred 3 days earlier, the estimated profit shrank to 72,000 <euro> (46 % of estimated ICU profit). In situations where the decision to withdraw or withhold therapy from patients could have occurred 3 days later, the hypothetical profit rose to 217,000 <euro> (138 % of estimated ICU profit). There are still few patients with clear self-determination, and almost half of therapies are performed only according to presumed consent. The strong nonlinear dependence of DRG revenues on ventilation hours could influence ethical decision making of medical professionals. The decision-making process and appropriate therapy in the ICU setting need to be defined more clearly and better documented, focusing on the benefits to the patient while respecting patient consent.

Peritonectomy and hyperthermic intraperitoneal chemotherapy: Cost analysis and sustainability

BackgroundMalignancies of the peritoneum remain a challenge in any hospital that accepts to manage them, due not only to difficulties associated with the complexity of the procedures involved but also the costs, which – in Italy and other countries that use a diagnosis-related group (DRG) system – are not adequately reimbursed. Material and methodsWe analyzed data relative to 24 patients operated on between September 2010 and May 2013 with special regard to operating room expenditure, ICU stay, duration of hospitalization, and DRG reimbursement. The total costs per patient included clinical, operating room, procedure, pathology, imaging, ward care, allied healthcare, pharmaceutical, and ICU costs. ResultsPostoperative hospital stay, drugs and materials, and operating room occupancy were the main factors affecting the expenditure for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. We had a median hospitalization of 14 days, median ICU stay of 2.4 days, and median operating room occupancy of 585 min. The median expenditure for each case was € 21,744; the median reimbursement by the national health system € 8,375. ConclusionsIn a DRG reimbursement system, the economic effort in the management of patients undergoing peritonectomy procedures may not be counterbalanced by adequate reimbursement. Joint efforts between medical and administration parties are mandatory to develop appropriate treatment protocols and keep down the costs.

ERRATUM: Correction of numbering used for citing Tables: Evaluating the efficacy of the current diagnosis-related group reimbursement system for laparoscopic appendectomy at a single institute in Korea

ERRATUM: Correction of numbering used for citing Tables: Evaluating the efficacy of the current diagnosis-related group reimbursement system for laparoscopic appendectomy at a single institute in Korea

Evaluating the efficacy of the current diagnosis-related group reimbursement system for laparoscopic appendectomy at a single institute in Korea.

PurposeThe diagnosis-related group (DRG) system has been adapted to reduce overall medical costs by grouping and classifying relatively homogenous patients based on similar resource consumption patterns in the treatment. However, despite its wide range of disease manifestation from early inflammation to severe peritonitis, acute appendicitis is included in the DRG system. Responding to a need to assess the DRG system for patients diagnosed with appendicitis, this study evaluates the efficacy of the current DRG system applied to a broad spectrum of the patients with appendicitis undergoing laparoscopic appendectomy.MethodsA retrospective review was conducted of the patients who underwent laparoscopic appendectomy. Based on the DRG codes' classification, the patients were analyzed for the amount of DRG reimbursement and the total in-patient cost in relation to the time sequence of the disease onset. Statistical analysis was performed to find factors correlated with the DRG reimbursement and total in-patient cost.ResultsFindings indicate that, as the symptom duration becomes prolonged, the CRP level and the use of peritoneal drainage increased. Patients with a symptom duration greater than 24 hours required approximately 5 days of hospital stay, 0.5 day longer in the length of hospital stay than that of patients with less than 12 hours of the onset time. As expected, the amount of DRG reimbursement and the total in-patient cost accumulated as the symptom duration increased.ConclusionThe current DRG reimbursement system for the patients undergoing laparoscopic appendectomy recompenses a broad spectrum of patients diagnosed with appendicitis effectively.

Prozessoptimierung auf der Stroke Unit

Die sehr personalintensive Struktur einer Stroke Unit wird bei der derzeitigen DRG-Vergütung systematisch unterfinanziert. Daher stehen Stroke Units unter besonderem Druck, zur Selbsterhaltung alle Möglichkeiten der Kostenreduktion zu nutzen, ohne jedoch die Qualität der Behandlung zu verschlechtern. Die Autoren beschreiben Möglichkeiten der Prozessoptimierung, die am Universitätsklinikum Münster durchgeführt wurden und neben qualitativen Verbesserungen auch zu einer Verbesserung der Wirtschaftlichkeit der Leistungserbringung beigetragen haben.

Cost estimation of small bowel capsule endoscopy based on “real world” data: Inpatient or outpatient procedure?

Background Although capsule endoscopy is the cornerstone for the evaluation of the small bowel in patients with obscure GI bleeding data about costs are lacking. Aim To evaluate, from a third party payer point of view, whether performing capsule endoscopy as an outpatient instead of an inpatient procedure can reduce costs. Materials and methods The data source is a multicentre survey collecting data for 2921 patients; 1486 of them underwent capsule endoscopy for obscure GI bleeding or chronic unexplained iron-deficiency anaemia as inpatients (814 with positive, 211 with inconclusive and 461 with negative result). We estimated costs of inpatient procedures based on the diagnosis related groups (DRG) system, while those of outpatient procedures on reimbursement provided in five Italian regions. Results We estimated that the cost for each inpatient undergoing capsule endoscopy is about € 1775.90. Assuming that all these patients had undergone the same procedure as outpatients, € 175.00–741.00 per patient (depending on the reimbursement and/or on diagnosis related group codes applied) would have been saved. Conclusions Our estimate suggests that, from the third party payer's perspective and using the diagnosis related group reimbursement system, shifting capsule endoscopy from inpatient to outpatient procedure, would be potentially cost saving at least for patients referred for obscure GI bleeding or chronic unexplained anaemia.

People admitted to hospital with physical disability have increased length of stay: implications for diagnosis related group re-imbursement in England

to assess whether measures of cognitive and physical function can explain differences in observed and healthcare resource group (HRG) predicted length of stay for patients presenting with six target conditions at admission. prospective observational study. three East Kent district general hospitals. One thousand nine hundred and forty-two consecutive emergency admissions, from March to July 2004, with ne or more of six presenting conditions (stroke, fracture neck of femur, myocardial infarction, acute respiratory infection, chronic obstructive airways disease and falls). length of stay by physical and cognitive function score adjusted for HRG allocated at discharge and other covariates. Physical function was defined using Activities of Daily Living Hierarchy Scale and cognitive function using the Cognitive Performance Scale. median difference between observed and HRG predicted length of stay was 1.2 days (25th percentile estimate, 3.9; 75th percentile estimate, 10.1) for patients with high physical dependency. They stayed 40% longer (95% confidence interval 26-56%) than patients with lower physical dependency after excluding effects of HRG and other covariates. Results are not consistent for cognitive function scores, mainly because most patients had no cognitive impairment. these patients, presenting with conditions common in older patients, would have incurred estimated annual costs of pound 1.9 million in excess of their HRG tariff-based re-imbursement. Physical function, defined by the degree of dependency in activities of daily living, should be incorporated into HRGs to reduce the financial risk faced by acute hospital services under Payment by Results, the UK diagnosis related group re-imbursement system.

Infection control in German nursing homes

Infection control in German nursing homes has become an issue during the past 10 years. The changing demographics and the introduction of the diagnosis-related group reimbursement system, as well as the increasing number of residents who are colonized with methicillin-resistant Staphylococcus aureus, may worsen already-existing infection control problems. The publication of national infection control guidelines for nursing homes that should be implemented and supervised by infection control nurses may increase the standard. However, the lack of responsibility of the caring physicians for the whole population of a nursing home may hinder the process. This article discusses the state of infection control in German nursing homes.

Quality still doesn't pay in heart failure management

Virtually every contemporary discussion of heart failure starts with an obligatory citation of statistics that make 3 basic points: First, the disease is quite prevalent in North America and Europe. Second, in aggregate, heart failure is one of the most expensive of diseases, with much of the expense concentrated in the elderly population (eg, >65 years). And finally, both the prevalence and associated expense are expected to increase dramatically in the next 25 years. In part, the coming epidemic of heart failure is being created by our partial therapeutic victories of the past 25 years. We are much better than we used to be at keeping patients with coronary disease alive, but we do less well at keeping them healthy and fully functional. As Lewis Thomas pointed out more than 30 years ago, such “halfway technologies” are usually enormously expensive. In heart failure, much of the expense is attributable to the need for hospitalizations for episodes of decompensation. These “failures” of outpatient care may relate in part to the deficiencies of our current therapeutic tools. In particular, we still have no practical way to replace dead heart muscle. However, a growing body of evidence suggests that a significant portion of these decompensations can be attributed to our failure to aggressively apply in practice what we know. For example, we know from large well-done clinical trials that angiotensinconverting enzyme (ACE) inhibitors and -blockers can both improve survival and reduce the need for hospitalizations in heart failure patients. As highlighted in a recent report from the Institute of Medicine, however, these life-saving therapies remain significantly underused in clinical practice. The gap between what we know and what we do in heart failure management has been described as a “quality chasm.” One important set of strategies designed to bridge gaps in the quality of conventional medical care consists of process of care interventions broadly referred to as “disease management.” These programs contain a variable mix of patient education, optimization of congestive heart failure (CHF) therapies, interventions to improve compliance, and early problem solving to prevent the need for subsequent hospital-based care. Some programs consist of a nurse calling a patient over the phone, whereas others involve a team of specialists providing support to the patient at the direction of a designated coordinator. Some programs begin during a hospitalization for heart failure, whereas others are initiated in the outpatient setting. The overarching concept is to provide a means to identify vulnerable patients who are getting into trouble early and to provide preemptive problem solving so that need for hospitalization can be avoided. A meta-analysis of 11 randomized trials of disease management programs published through 1999 found a significant 23% decrease in hospitalization rate for the multidisciplinary form of disease management, but no effect of the telephone based type. In this issue of the Journal, McDonald and Ledwidge propose that disease management strategies should be extended to the inpatient phase of care for CHF. In particular, the authors recommend a structured program involving care by a cardiologist, use of proven medical therapies in proper dosage, education of the patient and family by a specialist heart failure nurse, and use of explicit criteria to assess discharge readiness. In a preliminary report of a randomized trial of this multidisciplinary program, with 70 patients enrolled there were no rehospitalizations out to 1 month for the new program or for conventional care. In contrast, the hospitalization From the Duke University Medical Center, Durham, North Carolina, and Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, North Carolina. Reprint requests: Daniel B. Mark, MD, MPH, Professor of Medicine, Duke Clinical Research Institute, 2400 Pratt Avenue, Room 0311, Durham, NC 27705. © 2003 Elsevier Inc. All rights reserved. 1071-9164/03/0904-0004$30.00/0 doi:10.1054/jcaf.2003.52 Journal of Cardiac Failure Vol. 9 No. 4 2003

Viability, Morbidity, and Resource Use Among Newborns of 501-to 800-g Birth Weight

<h3>Objectives.</h3> —To assess risk factors affecting viability and analyze the effects of mechanical ventilation (MV) on neonatal outcome and resource use among extremely premature infants. <h3>Design.</h3> —Inception cohort study. <h3>Setting.</h3> —Neonatal intensive care units of the 12-center National Institute of Child Health and Human Development Neonatal Research Network. <h3>Participants.</h3> —A total of 1126 infants with a birth weight of 501 to 800 g born in network centers between January 1, 1994, and December 31, 1995. <h3>Main Outcome Measures.</h3> —Observed survival; maximum estimated survival (assuming the same survival among infants who died without MV as among infants in the same risk category who received MV); observed and maximum estimated survival without severe brain injury (either interventricular echodensity with ventricular dilation or parenchymal echodensity); hospital stay; resource investment. <h3>Results.</h3> —Overall mortality was 43%; mortality in infants without MV was 93%. A total of 15% of all the infants died without MV. Females, small-for-gestational-age infants, and infants whose mothers received antenatal steroids had an advantage in survival with MV equivalent to an increase in birth weight of 90 g, 57 g, and 67 g, respectively. The corresponding advantage of these infants in survival without severe brain injury was 107 g, 97 g, and 64 g, respectively. Females in the lowest birth-weight group were more likely to die without MV than were larger males with a similar estimated likelihood of survival with MV. Mean hospital stay was 115 days for the survivors, values much greater than the 17.9-day standard for 501- to 800-g survivors under the diagnosis related group system. Resource investment was considerable (127 hospital days per survivor and 148 days per survivor without severe brain injury), but, like outcome, varied markedly between risk categories. Had MV been used for all infants who died, we estimate a substantial increase in resource use and a maximum of 8 additional survivors (no more than 6 without severe brain injury per 100 infants with a birth weight of 501 to 800 g. <h3>Conclusions.</h3> —Although recommendations to initiate or forgo MV for extremely premature infants have often focused on 1 factor (birth weight or gestational age), multiple factors should be considered. Other factors being equal, our analyses support use of MV for females at a minimum birth weight approximately 100 g lower than that for males. The current diagnosis related group reimbursement system can be expected to compromise resources for 501- to 800-g infants who would benefit from MV. Such care entails considerable resource use, although the cost per lifeyear gained is likely to be considerably less than that for many adults given intensive care. Our findings can be used to facilitate more appropriate treatment decisions, determine adequate resources, and better inform the debate about the benefits and burdens of intensive care for extremely premature newborns.

Viability, morbidity, and resource use among newborns of 501- to 800-g birth weight. National Institute of Child Health and Human Development Neonatal Research Network

To assess risk factors affecting viability and analyze the effects of mechanical ventilation (MV) on neonatal outcome and resource use among extremely premature infants. Inception cohort study. Neonatal intensive care units of the 12-center National Institute of Child Health and Human Development Neonatal Research Network. A total of 1126 infants with a birth weight of 501 to 800 g born in network centers between January 1, 1994, and December 31, 1995. Observed survival; maximum estimated survival (assuming the same survival among infants who died without MV as among infants in the same risk category who received MV); observed and maximum estimated survival without severe brain injury (either interventricular echodensity with ventricular dilation or parenchymal echodensity); hospital stay; resource investment. Overall mortality was 43%; mortality in infants without MV was 93%. A total of 15% of all the infants died without MV. Females, small-for-gestational-age infants, and infants whose mothers received antenatal steroids had an advantage in survival with MV equivalent to an increase in birth weight of 90 g, 57 g, and 67 g, respectively. The corresponding advantage of these infants in survival without severe brain injury was 107 g, 97 g, and 64 g, respectively. Females in the lowest birth-weight group were more likely to die without MV than were larger males with a similar estimated likelihood of survival with MV. Mean hospital stay was 115 days for the survivors, values much greater than the 17.9-day standard for 501- to 800-g survivors under the diagnosis related group system. Resource investment was considerable (127 hospital days per survivor and 148 days per survivor without severe brain injury), but, like outcome, varied markedly between risk categories. Had MV been used for all infants who died, we estimate a substantial increase in resource use and a maximum of 8 additional survivors (no more than 6 without severe brain injury per 100 infants with a birth weight of 501 to 800 g. Although recommendations to initiate or forgo MV for extremely premature infants have often focused on 1 factor (birth weight or gestational age), multiple factors should be considered. Other factors being equal, our analyses support use of MV for females at a minimum birth weight approximately 100 g lower than that for males. The current diagnosis related group reimbursement system can be expected to compromise resources for 501- to 800-g infants who would benefit from MV. Such care entails considerable resource use, although the cost per life-year gained is likely to be considerably less than that for many adults given intensive care. Our findings can be used to facilitate more appropriate treatment decisions, determine adequate resources, and better inform the debate about the benefits and burdens of intensive care for extremely premature newborns.

The costs of burn care: an analysis with an emphasis on the use of parenteral antimicrobials.

Because infection is a common cause of morbidity and mortality in patients with burns and intensive antibiotic therapy is often required, the focus of this study was to describe the patterns of use and costs of parenteral antibiotics in a burn unit. The study also evaluated the overall economics of burn care in our population. Forty-one percent of the study group received parenteral antimicrobial agents; the specific agents, indications, and costs are described. The costs of parenteral antibiotics made up a negligible 1.2% of hospital costs and only 12.4% of pharmacy costs. This study revealed the continued hospital losses related to the reimbursement system used by diagnosis-related groups for patients with Medicare. If all patients studied (n = 61) were reimbursed under diagnosis-related groups the unit would have experienced an annual loss of approximately 1.2 million dollars. If specialized burn care facilities are to remain, it may be necessary to reevaluate the appropriateness of the diagnosis-related group reimbursement system for burn-related injury. This is especially important if all third-party reimbursement sources consider conversion to this system of compensation.

Mr Turner's Toenails: What's the Diagnosis Related Group?-Reply

In Reply.— As Dr Matz may have surmised, Mr Turner and I lived our story before the invention of diagnosis related groups. Sadly, the experience I had with Mr Turner may no longer be as available to medical students. Fortunately, there are other physicians who have found opportunities to continue to cut toenails despite the diagnosis related group reimbursement system. 1,2

A prospective study of delirium and prolonged hospital stay. Exploratory study.

Using explicit criteria, delirium was diagnosed in 15% of a cohort of 133 hospitalized patients. Following each patient's discharge or death, the length of stay was compared with the diagnosis related group-predicted length of hospitalization. An analysis of stay variations disclosed that delirious patients exceeded their predicted stay by an average of 13 days, while nondelirious patients exceeded theirs by 3.3 days. The mean (+/- SD) length of hospitalization for patients with delirium was significantly longer than for their nondelirious counterparts (21.6 +/- 23.7 days vs 10.6 +/- 10.1 days, respectively). Hospitals treating high proportions of patients with delirium as a comorbidity to a principal somatic diagnosis should institute measures for the early detection of and appropriate intervention in patients with this condition. These steps may help reduce prolonged hospitalizations and minimize financial risk under the current diagnosis related group reimbursement system.

Nosocomial infections, diagnosis-related groups, and study on the efficacy of nosocomial infection control: Economic implications for hospitals under the prospective payment system

It is obvious that escalating costs of medical care must be curbed. Fortunately, since the major proportion of health care costs relate to inpatient management, the diagnosis-related group “experiment” forces the medical community to examine carefully the costs of the specific components of health care delivery. One such item is the cost of nosocomial infections. With respect to the potential Importance of hospital-acquired infections and reimbursement under the diagnosis-related group system, several points should be underscored. Nosocomial infections represent a direct economic liability of $5 to $10 billion annually in the United States. Under the new diagnosis-related group reimbursement system, it is probable that very little of the costs related to excess stay resulting from infections will be reimbursed to hospitals. For the first time, there are data indicating that as much as one third of hospital-acquired infections can be prevented by implementing effective infection control programs. The currently available information suggests that under the existing diagnosis-related group reimbursement system, hospitals with effective infection control programs can significantly improve their economic position.