Diagnosis-related Group Reimbursement Research Articles

The implementation of DRG-based hospital reimbursement in Switzerland: A population-based perspective

BackgroundSwitzerland introduces a DRG (Diagnosis Related Groups) based system for hospital financing in 2012 in order to increase efficiency and transparency of Swiss health care. DRG-based hospital reimbursement is not simultaneously realized in all Swiss cantons and several cantons already implemented DRG-based financing irrespective of the national agenda, a setting that provides an opportunity to compare the situation in different cantons. Effects of introducing DRGs anticipated for providers and insurers are relatively well known but it remains less clear what effects DRGs will have on served populations. The objective of the study is therefore to analyze differences of volume and major quality indicators of care between areas with or without DRG-based hospital reimbursement from a population based perspective.MethodsSmall area analysis of all hospitalizations in acute care hospitals and of all consultations reimbursed by mandatory basic health insurance for physicians in own practice during 2003-2007.ResultsThe results show fewer hospitalizations and a relocation of resources to outpatient care in areas with DRG reimbursement. Overall burden of disease expressed as per capita DRG cost weights was almost identical between the two types of hospital reimbursement and no distinct temporal differences were detected in this respect. But the results show considerably higher 90-day rehospitalization rates in DRG areas.ConclusionThe study provides evidence of both desired and harmful effects related to the implementation of DRGs. Systematic monitoring of outcomes and quality of care are therefore essential elements to maintain in the Swiss health system after DRG's are implemented on a nationwide basis in 2012.

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.

Costs and reimbursement gaps after implementation of third-generation left ventricular assist devices

The purpose of this study was to compare and contrast total hospital costs and subsequent reimbursement of implementing a new program using a third-generation left ventricular assist device (LVAD) in Norway. Between July 2005 and March 2008, the total costs of treatment for 9 patients were examined. Costs were calculated for three periods-the pre-implantation LVAD phase, the LVAD implantation phase and the post-implantation LVAD phase-as well as for total hospital care. Patient-specific costs were obtained prospectively from patient records and included personnel resources, medication, blood products, blood chemistry and microbiology, imaging, and procedure costs including operating room costs. Overhead costs were registered retrospectively and allocated to the specific patient by pre-defined allocation keys. Finally, patient-specific costs and overhead costs were aggregated into total patient costs. The average total patient cost in 2007 U.S. dollars was $735,342 and the median was $613,087 (range $342,581 to $1,256,026). The mean length of stay was 77 days (range 40 to 127 days). For the LVAD implantation phase, the mean cost was $457,795 and median cost was $458,611 (range $246,239 to $677,680). The mean length of stay for the LVAD implantation phase was 55 days (range 25 to 125 days). The diagnosis-related group (DRG) reimbursement (2007) was $143,192. There is significant discrepancy between actual hospital costs and the current Norwegian DRG reimbursement for the LVAD procedure. This discrepancy can be partly explained by excessive costs related to the introduction of a new program with new technology. Costly innovations should be considered in price setting of reimbursement for novel technology.

Rate, type, and cost of pelvic organ prolapse surgery in Germany, France, and England

Objective To estimate the rate, type and costs of surgical interventions for pelvic organ prolapse (POP) in Germany, France, and England. Study design We identified the number, rate, and type of hospital admissions for pelvic floor surgery in 2005 from national hospital activity databases in each country: the German Hospital Episode, the French Medical Care Program Information System, and the National Health Service England Hospital Episode Statistics. Costs to the payer were estimated using the Diagnosis-Related Group reimbursement rates for each country. Results In 2005, the number (rate) of admissions for POP surgery was 36,854 (0.87 per 1000 women) in Germany, 36,679 (1.14 per 1000 women) in France, and 28,959 (1.13 per 1000 women) in England. Admissions for POP surgery constituted 10.4%, 16.7% and 16.9% of all admissions for female genital tract therapeutic interventions in Germany, France and England, respectively. At least 20% of hysterectomies were performed for the primary indication of POP. 57.4%, 45.0%, and 40.1% of all admissions for POP surgery included a hysterectomy. The costs to payers were €144,236,557, €83,067,825, and €81,030,907 in Germany, France, and England, respectively. Conclusion Burden and costs associated with POP surgery are substantial in the three countries studied. Thus, programs aimed at reducing the burden of this disease are desirable.

Rate, Type, and Cost of Invasive Interventions for Uterine Myomas in Germany, France, and England

Study Objective The objective of our study was to quantify the rate, type, and cost of interventions for uterine myomas to payers in Germany, France, and England. Design Computations using data from national hospital activity databases. Design classification: II-3. Setting Hospital admissions in Germany, France, and England. Patients Women admitted for a surgical or radiologic intervention for uterine myomas. Interventions Surgical or radiologic interventions for uterine myomas. Measurements and Main Results We identified the number and type of hospital admissions involving surgical or radiologic interventions for uterine myomas, through the analysis of national hospital activity databases from each country. We calculated the costs of these hospitalizations to payers in these countries using the diagnosis-related group reimbursement rates. In 2005, the number (rate) of hospital admissions involving interventions for uterine myomas was 64 299 (1.53/1000 women) in Germany, 37 787 (1.17/1000 women) in France, and 18 274 (0.71/1000 women) in England. The annual costs of these interventions to payers were €212 313 090 in Germany, €73 278 270 in France (excluding surgeon and anesthetist fees for interventions in the private sector), and €52 674 672 in England. The percentage of interventions for uterine myomas that included a hysterectomy was 84.9% in Germany, 59.7% in France, and 64.1% in England. Conclusion The number of admissions and costs associated with interventions for uterine myomas are substantial in the 3 European countries studied. Hysterectomy is the most frequent surgical intervention used to treat uterine myomas. The results in this article provide useful information for policy makers wishing to evaluate the cost effectiveness and budget impact of new, less invasive interventions.

Acute Myocardial Infarction and Race, Sex, and Insurance Types

Cardiovascular disease is the leading cause of death among men and women in the United States. Georgia's death rate from cardiovascular disease is higher than the national rate. Previous studies have suggested that whites and African Americans do not receive the same processes of care for a first episode of acute myocardial infarction, one of many cardiovascular disease pathologies. Patient's insurance type, race, sex, and whether a patient lives in a rural or urban area have also been suggested as explanations for unequal processes of care for the treatment of acute myocardial infarction. Using diagnosis-related group reimbursement data from an academic medical center in Georgia, this study found independent effects for race (p < .001) and payer status (p = .004), after adjusting for fiscal year. Possible causes for these differences, as well as recommendations for further study, are explored.

Thoracic aortic aneurysm repair. Direct hospital cost and Diagnosis Related Group reimbursement

Objective. The main objective of this study was to analyze direct hospital cost and to compare cost with existing DRG reimbursement for open repair of thoracic and thoraco-abdominal aortic disease. Study sample and methodology. Between January 2003 and September 2003, the cost of treatment for 24 surgical procedures on ascending aorta and arch, descending or thoraco-abdominal aortic disease were examined prospectively. Seven patients had urgent or emergency surgeries. Ten had sternotomies for disease of the ascending aorta and aortic arch; two had left thoracotomies and three thoraco-laparotomy incisions with procedures performed on x-corporeal circulation. Nine other patients had more distal thoraco-abdominal aortic operations with a clamp-and-sew technique. Micro-cost analysis was performed on each hospital stay, in addition overhead hospital costs were allocated to each procedure. Results. The patients were grouped by discharge diagnosis (ICD-10) and surgical procedure performed (NCSP) into Norwegian DRG code. Patient with surgery on ascending aorta & aortic arch were allocated to DRG 108 (n =9) or 483 (tracheostomy, n =1) while patient with surgery on descending or thoraco-abdominal aorta were allocated to DRG 108 (n =3), 110 (n =4), 111 (n =4) or 483 (tracheostomy, n =3). The mean EuroSCORE for patients with proximal aortic disease was 11 , and the length of stay was 5 days (range 3–8 days), spending 2 days (range 1–7 days) in thoracic intensive care unit. For patients with distal aortic disease the mean Euroscore was 7 , and the mean length of stay 10 days (range 4–23 days) with a mean 4 days (range 1–13 days) in intensive care unit. Eight patients developed medical problems requiring new surgical procedures or prolonged ICU stay. The average direct hospital cost for proximal aortic surgery was USD 15 877 (USD 1 =NOK 7.5) while the respective 100% DRG reimbursement including one patient needing a tracheostomy, was 19 803 USD. For patients with distal aortic disease, average direct hospital cost was 23 005 USD and DRG reimbursement including patients needing a tracheostomy was 31543 USD. Conclusion. Our results underscore previous findings that these patients are resource intensive. This study shows that Norwegian 100% DRG reimbursement did over-compensate observed total hospital costs in this cohort. Detailed analysis showed that this was due to the higher DRG reimbursement for patients needing prolonged ventilatory support. Thus the actual DRG reimbursement seems to be relevant to the tertiary hospital actual costs when these complicated patients are considered as a group. It remains however unclear whether this reimbursement is sufficient to support the scientific infrastructure for new knowledge and skills needed for the further refinement of treatment.

Economic appraisal of the angioplasty procedures performed in 2004 in a high-volume diagnostic and interventional cardiology unit

Growing interest in the use of drug-eluting stents (DESs) in coronary angioplasty has prompted the Healthcare Agency of the Emilia Romagna Region to draw up recommendations for their appropriate clinical use in high-risk patients. Since the adoption of any new technology necessitates economic appraisal, we analysed the resource consumption of the various types of angioplasty procedures and the impact on the budget of a cardiology department. A retrospective economic appraisal was carried out on the coronary angioplasty procedures performed in 2004 in the Department of Interventional Cardiology of Reggio Emilia. On the basis of the principles of activity-based costing, detailed hospital costs were estimated for each procedure and compared with the relevant diagnosis-related group (DRG) reimbursement. In 2004, the Reggio Emilia hospital performed 806 angioplasty procedures for a total expenditure of euro 5,176,268. These were 93 plain old balloon angioplasty procedures (euro 487,329), 401 procedures with bare-metal stents (euro 2,380,071), 249 procedures with DESs (euro 1,827,386) and 63 mixed procedures (euro 481,480). Reimbursements amounted to euro 5,816,748 (11% from plain old balloon angioplasty, 50% from bare-metal stent, 31% from DES and 8% from mixed procedures) with a positive margin of about euro 680,480 between costs incurred and reimbursements obtained, even if the reimbursement for DES and mixed procedures was not covering all the incurred costs. Analysis of the case-mix of procedures revealed that an overall positive margin between costs and DRG reimbursements was achieved. It therefore emerges that adherence to the indications of the Healthcare Agency of the Emilia Romagna Region for the appropriate clinical use of DESs is economically sustainable from the hospital enterprise point of view, although the DRG reimbursements are not able to differentiate among resource consumptions owing to the adoption of innovative technologies.

C-reactive protein and delirium in acute ill elderly patients

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Direct Costs in Patients Hospitalised with Community-Acquired Pneumonia After Non-Response to Outpatient Treatment with Macrolide Antibacterials in the US

Antibacterial cost-containment programmes emphasise the use of narrow-spectrum generic agents whenever possible. The use of these agents is driven by their lower purchase prices; the consequences of treatment failure are rarely considered. This study was conducted to identify the costs of treating patients hospitalised with community-acquired pneumonia (CAP) associated with Streptococcus pneumoniae following failure to respond to outpatient treatment with macrolide antibacterials. A multicentre, retrospective, observational study was performed in patients with CAP due to S. pneumoniae who were admitted to 31 North American hospitals following a lack of response to >or=2 days of outpatient treatment with a macrolide antibacterial. Direct medical costs (year 2004 values) of infection-related hospital resources, including antibacterials (purchase, preparation, dispensing, administration and monitoring), diagnostic tests, therapeutic procedures, treatment of adverse events and therapeutic failures, and hospitalisation per diem (ward, critical care and ventilator days), were analysed. Total hospital costs were then compared with standard diagnosis-related group (DRG) reimbursement. A total of 122 patients were enrolled. Patients were frequently bacteraemic (52%) and infected with macrolide-resistant strains of S. pneumoniae (71%). Initial inpatient antibacterial treatment was not successful in 17 patients (14%) and seven patients (5.7%) died. The mean length of stay was 8.7 days (SD 7) including 1.3 days (SD 2.9) in a critical care unit and 1.4 days (SD 4.4) of mechanical ventilation. The mean cost of hospitalisation was US dollars 12,678 (SD 13 346) but standard DRG reimbursement averaged only US dollars 8,634. Patients who do not respond to outpatient treatment with a macrolide antibacterial and who are subsequently hospitalised with CAP caused by S. pneumoniae are likely to be infected with a non-susceptible strain, are frequently bacteraemic, are at an increased risk for mortality compared with previously published estimates in patients with CAP due to S. pneumoniae, and incur hospital costs that far exceed standard DRG reimbursement for CAP.

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.

Nursing Cost by DRG: Nursing Intensity Weights

Although diagnosis-related group (DRG) reimbursement is used for Medicare and many other payors, nursing--the largest portion of hospital costs--is not specifically identified and quantified in deriving payments in any of the DRG reimbursement systems except that of New York State. In New York, nursing costs are allocated to each DRG in payment rate formulation by means of nursing intensity weights (NIWs)--relative values reflecting the quantity and types of nursing services provided to patients in each DRG. In the absence of charges for nursing services, these NIWs are derived from scores for each DRG provided by a representative panel of nurses through a modified Delphi technique. NIWs have been shown to correlate with hospitals' nursing costs per day. They are used to set cost-based payment weights, thereby avoiding compression caused by using flat cost-to-charge or cost-per-day averages for all acute and intensive care patients.

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.

Hospital Volume Outcome and Discharge Disposition of Burn Patients

The purpose of this investigation was to determine the impact of hospital clinical volume on patient outcomes (i.e., in-hospital mortality, length of stay) and discharge disposition of burn patients using a large nationally representative database. Patient data were obtained from the 1999-2001 National Inpatient Sample using burn diagnosis-related group codes 504 through 511. Hospitals were segregated into high-volume hospitals (treating more than 100 patients per year), medium-volume hospitals (treating 20 to 99 patients per year), and low-volume hospitals (treating fewer than 20 patients per year). Mortality, length of stay, and discharge disposition were catalogued for each diagnosis-related group code and hospital type. In diagnosis-related group pair 504/505 (most severe), the mortality rate in patients admitted to high-volume hospitals (33.5 percent) was significantly higher than in patients admitted to both medium-volume hospitals (28.8 percent) and low-volume hospitals (11.5 percent) (p = 0.002). Within lower severity diagnosis-related groups, where the mortality rate was lower across all admissions, medium-volume hospitals and high-volume hospitals had a higher proportion of routine discharges to home, a lower need for home care, and a lower proportion of transfers compared with low-volume hospitals. Despite shorter length of stay, across most burn diagnosis-related groups, patients admitted to low-volume hospitals had lower rates of routine discharges and a higher proportion of admissions "with complications." Higher-volume facilities, despite receiving the most severe burn patients, may provide better patient outcomes than lower-volume facilities. The patterns of discharges found at lower-volume facilities may result in higher diagnosis-related group reimbursement "capture" by lower-volume facilities and higher postdischarge resource use.

Hospital resources consumed for surgical morbidity: effects of preoperative arginine and ω-3 fatty acid supplementation on costs

Objective Costs related to postoperative complications continue to be a major burden on any health care system. The aim of the present study was to calculate hospital costs for postoperative complications and to evaluate whether preoperative supplementation with ω-3 fatty acids and arginine (specialized diet) might lead to cost savings in patient care. Methods Blind analysis of costs performed on data gathered from a randomized clinical trial carried out on 305 patients with gastrointestinal cancer showed that an oral preoperative specialized diet decreased postoperative morbidity compared with conventional treatment (no supplementation). Estimates of complication costs were based on resources used for treatment and on additional length of hospital stay. Cost-comparison and cost-effectiveness analyses were then carried out. Results The mean cost of postoperative complications was €4492. The greatest amount of resources was consumed by 19 anastomotic leaks (€159803), 18 abdominal abscesses (€112921), and 18 pancreatic fistulae (€106516). The mean costs per complication were €6178 in the conventional group and €4639 in the preoperative group ( P = 0.05). The mean total costs of patients with complications were €10494 in the conventional group and €8793 in the preoperative group. The mean cost per randomized patient was €3122 in the conventional group versus €1872 in the preoperative group ( P = 0.04). Effectiveness values were 50.0% in the conventional group and 62.8% in the preoperative group ( P = 0.03). Total costs consumed 93% of the diagnosis-related group reimbursement rate in the conventional group and 78% in the preoperative group. Conclusions The costs of postoperative morbidity consumed a large amount of the diagnosis-related group reimbursement rate. Preoperative supplementation with the specialized diet appears to be a cost-effective treatment.

Cost Comparison of Surgery vs Organ Preservation for Laryngeal Cancer

To perform a cost minimization analysis of total laryngectomy with postoperative radiotherapy vs induction chemotherapy with subsequent radiotherapy in patients with advanced (stage III or IV) squamous cell carcinoma of the larynx. Decision-analysis model using data from peer-reviewed trials, case series, meta-analyses, and Medicare diagnosis related group reimbursement rates. A hypothetical cohort of patients with stage III or IV laryngeal cancer. The perspective is that of a health care payer. The hypothetical patient cohort could receive (1) surgery (total laryngectomy) with postoperative radiotherapy or (2) induction chemotherapy (fluorouracil and cisplatin) with radiotherapy followed by salvage surgery for patients failing to respond to chemotherapy. Overall difference in direct medical costs in 2003 US dollars between the 2 treatment arms from initiation to completion of treatment. In the baseline analysis, the direct medical costs for the surgical arm were 30,138 US dollars per patient. For the organ preservation arm, the direct medical costs were 33,052 US dollars per patient. The finding that the surgical arm costs were lower was robust to all sensitivity analyses except for the extreme low estimate for the cost of chemotherapy. Our results suggest that total laryngectomy with postoperative radiotherapy costs nearly 3000 US dollars less than organ preservation treatment for advanced laryngeal cancer. Given that survival appears equivalent between the 2 modalities, cost consideration and patient preference may be important factors in decision making for the treatment of advanced laryngeal cancer.

Preoperative Immunonutrition: Cost‐Benefit Analysis

To evaluate whether preoperative immunonutrition might lead to a savings in patient care. Data on resources consumed to treat postoperative complications are scanty, but morbidity costs continue to be a major burden for any health care system. A recent randomized clinical trial carried out in well-nourished patients with gastrointestinal cancer showed that a 5-day preoperative oral immunonutrition reduced postoperative morbidity compared with conventional treatment (no supplementation). The abovementioned trial was the basis for the economic evaluation. In-hospital related costs of routine surgical care and costs of nutrition were calculated. Estimates of complication costs were based on both resources used for treatment and additional length of hospital stay. Cost comparison and cost-effectiveness analysis were then carried out. Total cost of nutrition was 3407 euro in the conventional group and 14,729 euro in the preoperative group. In patients without complication, the cost of in-hospital routine care was similar in both groups. The mean cost of complication was 6178 euro in the conventional group and 4639 euro in the preoperative group (p = .05). Total cost of patients with complications was 535,236 euro in the conventional group and 334,148 euro in the preoperative group. Total costs consumed 93% of the diagnosis-related-group (DRG) reimbursement rate in the conventional group and 78% in the preoperative group. Cost-effectiveness was 6245 euro for the conventional group and 2985 euro for the preoperative group. The costs of postoperative morbidity consumed a large amount of the DRG reimbursement rate. Preoperative immunonutrition was cost-effective in our series.

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

The added cost of urgent cholecystectomy to health systems.

The purpose of this study is to assess the cost and reimbursement differential between elective and urgent laparoscopic cholecystectomy. All visits for laparoscopic cholecystectomy (ICD-9 Code 51.23) to the University of Michigan Health System were reviewed for 1997 to 2001 (n = 752). Data were obtained from the University of Michigan Data Warehouse. Patients were grouped into urgent and elective cases, and further subgrouped into complicated and uncomplicated cases based on Diagnostic Related Group (DRG) coding. Total costs were determined for 13 distinct facility cost centers with average costs greater than $10 per case. Reimbursement was also assessed. Total costs were approximately 90% higher in urgent cases. The largest contributors to increased costs were nursing care and pharmacy costs. The emergent group experienced a pre-operative delay to surgery of 1.8 days. Reimbursement was similar for both elective and urgent patients when stratified by complicated and uncomplicated DRGs. The urgency of the operation significantly elevates the costs and resource consumption associated with laparoscopic cholecystectomy. These cost differences should also be recognized when setting reimbursement premiums under risk-bearing systems, such as Medicare Diagnosis Related Group reimbursement. Consideration for including urgent operation as a comorbidity should be assessed.