Diagnosis-related Groups System Research Articles

Comparison of posterior capsular rupture rates during phacoemulsification using 3D heads-up visualization system and traditional microscopes.

To compare the posterior capsular rupture (PCR) rates of cataract surgery using a traditional ophthalmic surgical microscope (OSM) and a three-dimensional (3D) heads-up visualization system (HUVS). Single tertiary referral center. Retrospective study. This study included 10,101 eyes that underwent phacoemulsification cataract surgery. Surgeries were performed using either 3D HUVS (1,964 eyes, performed by two surgeons, HUVS group) or traditional OSM (8,137 eyes, performed by six surgeons, OSM group) from February 2018 to June 2022. Data were collected based on the diagnosis-related group system, and the rate of PCR requiring vitrectomy and the surgical time were evaluated. The PCR rates were not significantly different between the OSM (n = 63; 0.7%) and HUVS (n = 19; 0.9%, p = 0.392) groups. The mean surgical times was significantly longer in the HUVS group (14.7 ± 10.6 min) than in the OSM group (12.9 ± 9.9 min, p < 0.001). In the 3D HUVS group, there were no PCR cases among the initial 100 patients. In both groups, no significant difference was observed in the PCR rates over time. Although the difference was not statistically significant, the PCR rate decreased over time in the HUVS group. Our results indicate that 3D HUVS-based cataract surgery performed by experienced cataract surgeons had a PCR rate similar to that of traditional OSM-based surgery during the 4-year study period. Although the surgical time was slightly longer with 3D HUVS, cataract surgery using 3D HUVS can be performed safely by experienced surgeons.

In-Hospital Pulmonary Arterial Embolism after Catheter Ablation of Over 45,000 Cardiac Arrhythmias: Individualized Case Analysis of Multicentric Data.

Data on incidence of in-hospital pulmonary embolisms (PE) after catheter ablation (CA) are scarce. To gain further insights, we sought to provide new findings through case-based analyses of administrative data. Incidences of PE after CA of supraventricular tachycardias (SVT), atrial fibrillation (AF), atrial flutter (AFlu), and ventricular tachycardias (VT) in three German tertiary centers between 2005 and 2020 were determined and coded by the G-DRG (German Diagnosis Related Groups System) and OPS (German Operation and Procedure Classification) systems. An administrative search was performed with a consecutive case-based analysis. Overall, 47,344 ablations were analyzed (10,037 SVT; 28,048 AF; 6,252 AFlu; 3,007 VT). PE occurred in 14 (0.03%) predominantly female (n = 9; 64.3%) patients with a mean age of 55.3 ± 16.9 years, body mass index 26.2 ± 5.1 kg/m2, and left ventricular ejection fraction of 56 ± 13.6%. PE incidences were 0.05% (n = 5) for SVT, 0.02% (n = 5) for AF, and 0.13% (n = 4) for VT ablations. No patient suffered PE after AFlu ablation. Five patients (35.7%) with PE after CA had no prior indication for oral anticoagulation (OAC). Preprocedural international normalized ratio in PE patients was 1.2 ± 0.5. Most patients with PE following CA presented with symptoms the day after the procedure (n = 9) after intraprocedural heparin application of 12,943.2 ± 5,415.5 IU. PE treatment included anticoagulation with either phenprocoumon (n = 5) or non-vitamin K-dependent OAC (n = 9). Two patients with PE died after VT/AF ablation, respectively. The remaining patients were discharged without sequels. Over a 15-year period, incidence of PE after ablation is low, particularly low in patients with ablation for AF/AFlu. This is most likely due to stricter anticoagulation management in these patients compared with those receiving SVT/VT ablation procedures and could argue for continuation of OAC prior to ablation. Optimizing periprocedural anticoagulation management should be subject of further prospective trials.

The role of human capital and stress for cost awareness in the healthcare system: a survey among German hospital physicians

BackgroundGermany has the highest per capita health care spending among EU member states, but its hospitals face pressure to generate profits independently due to the government’s withdrawal of investment cost coverage. The diagnosis related groups (DRG) payment system was implemented to address the cost issue, challenging hospital physicians to provide services within predefined prices and an economic target corridor to reduce costs. This study examines the extent of cost awareness among medical personnel in German hospitals and its influencing factors.MethodsWe developed an online survey in which participants across all specialties in hospitals estimated the prices in euros of four common interventions and answered questions about their human capital and perceived stress on the workplace. As a measure of cost awareness, we used the probability of estimating the prices correctly within a reasonable margin. We employed logit logistic regression estimators to identify influencing factors in a sample of 86 participants.ResultsThe results revealed that most of the respondents were unaware of the costs of common interventions. General human capital, acquired through prior education, and job-specific human capital had no influence on cost awareness, whereas domain-specific human capital, that is, gaining economic knowledge based on self-interest, had a positive nonlinear effect on cost awareness. Furthermore, an increased stress level negatively influenced cost awareness.ConclusionsThis paper is the first of its kind for the German health care sector that contributes responses to the question whether health care professionals in German hospitals have cost awareness and if not, what reasons lie behind this lack of knowledge. Our findings show that the cost awareness desired by the introduction of the DRG system has yet to be achieved by medical personnel.

Current scenario and challenges of clinical pharmacists to implement pharmaceutical care in DRG/DIP payment hospitals in China: a qualitative interview study.

The Diagnosis-Related Group (DRG) or Diagnosis-Intervention Packet (DIP) payment system, now introduced in China, intends to streamline healthcare billing practices. However, its implications for clinical pharmacists, pivotal stakeholders in the healthcare system, remain inadequately explored. This study sought to assess the perceptions, challenges, and roles of clinical pharmacists in China following the introduction of the DRG or DIP payment system. Qualitative interviews were conducted among a sample of clinical pharmacists. Ten semi-structured interviews were conducted, either online or face to face. Thematic analysis was employed to identify key insights and concerns related to their professional landscape under the DRG or DIP system. Clinical pharmacists exhibited variable awareness levels about the DRG or DIP system. Their roles have undergone shifts, creating a balance between traditional responsibilities and new obligations dictated by the DRG or DIP system. Professional development, particularly concerning health economics and DRG-based or DIP-based patient care, was highlighted as a key need. There were calls for policy support at both healthcare and national levels and a revised, holistic performance assessment system. The demand for more resources, be it in training platforms or personnel, was a recurrent theme. The DRG or DIP system's introduction in China poses both opportunities and challenges for clinical pharmacists. Addressing awareness gaps, offering robust policy support, ensuring adequate resource allocation, and recognizing the evolving role of pharmacists are crucial for harmoniously integrating the DRG or DIP system into the Chinese healthcare paradigm.

Length of Stay Index – A Retrospective Chart Review on In-patient Dermatology Consults

Background and Objective: In monitoring inpatient care quality and efficiency, one metric of interest is Length of Stay (LOS) by diagnosis-related group (DRG) system and how this compares to peer institutions. Vizient Inc. provides a source of such benchmarking - collecting and analyzing individual case-level data from community and academic medical center hospitals nationwide. Using this data, Vizient calculates an expected LOS by DRGs and adjusts for severity of illness and other factors for inter-hospital comparison. Because LOS reduction is an important mechanism for improving outcomes and efficiency of care, The Department of Dermatology would like to understand which dermatologic consults are exceeding the Vizient expected LOS (LOS index &gt; 1). &#x0D; Project Methods: Consecutive charts of 663 patients with dermatology-related diagnoses in the inpatient setting at IU University and Methodist Hospitals between January 2021 and January 2023 were reviewed. Parameters identified included: category of dermatologic disorder, LOS index, time to consult, and quarter of encounter. Data was organized and analyzed using paired t-tests, linear regression, and descriptive statistics in JMP software. &#x0D; Results: The mean LOS index for Dermatology inpatient consults was 1.89 (n=469). Patients whose dermatologic diagnosis fell under chronic wound, mechanical, infectious, drug adverse event, autoimmune, neoplasm, inflammatory, vascular, and blistering had a significant increase in observed length of stay compared to expected length of stay (p &lt; 0.05). Time to dermatology consult was not found to correlate to shortening or prolonging LOS index. &#x0D; Potential Impact: The data from this review will help direct the Department of Dermatology to the dermatologic consults with the highest need for potential interventions.

An epidemic of cataract surgery in Korea: the effects of private health insurance on the National Health Insurance Service.

In Korea, the National Health Insurance Service (NHIS) covers essential healthcare expenses, including cataract surgery. To address concerns that private health insurance (PHI) might have inflated the need for such procedures, we investigated the extent of the PHI-attributable increase in cataract surgery and its impact on NHIS-reimbursed expenses. This retrospective, observational study uses nationwide claims data for cataract surgery from 2016 to 2020. We examined trends in utilization and cost, and we estimated the excess numbers of (1) cataract operations attributable to PHI and (2) types of intraocular lenses used for cataract surgery in 2020. Between 2016 and 2020, a 36.8% increase occurred in the number of cataract operations, with increases of 63.5% and 731.8% in the total healthcare costs reimbursed by NHIS and PHI, respectively. Over a 5-year period, the surgical rate per 100,000 people doubled for patients aged <65 years (from 328 in 2016 to 664 in 2020). Among the 619,771 cases in 2020 of cataract surgery reimbursed by the Korean diagnosis-related group system, more non-NHIS-covered intraocular lenses were used for patients aged <65 years than ≥65 years (68.1 vs. 14.2%). In 2020 alone, an estimated 129,311 excess operations occurred, accounting for an excess cost of US$115 million. A dramatic increase in the number and cost of cataract operations has occurred over the last 5 years. The PHI-related increase in operations resulted in increased costs to NHIS. Measures to curtail the non-indicated use of cataract surgery should be implemented regarding PHI.

Comprehensive evaluation of disease coding quality in gastroenterology and its impact on the diagnosis-related group system: a cross-sectional study

ObjectiveAccording to the diagnosis-related group (DRG) requirement, issues of diagnosis and procedure coding in the gastroenterology department of our hospital were analyzed and improvement plans were proposed to lay the foundation for effective implementation of DRGs.MethodsThe title page of case-history of 1600 patients admitted to the Department of Gastroenterology of this hospital from January 1, 2021 to December 31, 2021 was sampled as a data source, and the primary and other diagnostic codes, operation or procedure codes involved in the title page of case-history were categorized and statistically analyzed.ResultsOf the 531 cases treated with gastrointestinal endoscopy in our hospital in 2021, coding errors were identified in 66 cases and unsuccessful DRG enrollment in 35 cases, including 14 cases with incorrect coding of the primary diagnosis (8 cases with unsuccessful DRG enrollment), 37 cases with incorrect coding of the primary operation (23 cases with unsuccessful DRG enrollment), and 8 cases with incorrect coding of both the primary diagnosis and the primary operation (4 cases with unsuccessful DRG enrollment). Analysis of 66 inpatient cases with coding problems showed a total of 167 deficiencies, including 36 deficiencies in major diagnoses, 84 deficiencies in other diagnoses, and 47 deficiencies in surgery or operation coding.ConclusionThe accuracy of coding of disease diagnosis and surgical operation is the basis for the smooth implementation of DRGs. The medical staff of this hospital has poor cognition of DRGs coding and fails to recognize the important role of the title page of case-history quality to DRGs system, and their attention to DRGs and knowledge base of disease classification coding should be improved. In addition, the high incidence of coding errors, especially the omission of disease diagnosis, requires increased training of physicians and nurses on clinical knowledge and requirements for DRGs medical records, thereby improving the quality of medical cases and ensuring the accuracy of DRGs information.

Reform of hospital financing: revenue-independent flat rates for acute inpatient obstetrics facilities

The patient classification system according to diagnosis related groups (DRGs) is highly related to performance, which was the reason for its national introduction in the early 2000s. Since 2003, hospital services have therefore been remunerated via the DRG system by means of flat rates per case. With few exceptions, all hospital services were remunerated via these flat rates per case until 2019. In 2020, the personnel costs for the nursing staff working in the hospital bed were then covered by the DRG-classified remuneration in order to relieve the enormous economic cost pressure on the nursing staff employed in German hospitals. This pressure is particularly evident in hospital wards with a low proportion of elective procedures (such as obstetrics). The economic management of such hospital wards is challenging. Now an even more far-reaching health policy proposal is being made. According to this proposal, hospitals should be financed for their maintenance costs. This is to be done by means of normatively determined budgets. In this way, a financial relief of the hospitals on the one hand and the promotion of the quality of service provision on the other hand should succeed. In the following paper, the challenges of acute inpatient obstetrics due to the current and planned financing system are examined. For this purpose, six selected experts, who belong to very different levels of care in the hospital sector, give an outlook on the introduction of the reserved financing.

The Megaendoprosthesis in Revision Arthroplasty - a Cost-revenue Analysis in the aG-DRG System.

Megaendoprosthesis offer a viable treatment in complex revision arthroplasty cases with good functional outcome. In the context of a neoplastic indication, the diagnosis-related group (DRG) I95A is usually assigned with a relative weight of 4.906 (2021). In contrast, in revision arthroplasty, the appropriate DRG is assigned, depending on the joint replacement. The additional costs compared to the invoiced DRG are to be compensated by agreeing on hospital-specific individual fees. These complex revision arthroplasties set high technical and operative demands and are mainly performed in specialised departments. We conducted a cost-benefit analysis of the use of the megaendoprosthesis in revision cases in a specialised orthopaedic clinic, as a single centre study. The question we sought to answer was: Is cost recovery possible in the modified German DRG system (aG-DRG)?A retrospective single centre analysis of treatment costs was performed. From 2018 to 2020, 113 patients treated with a megaendoprosthesis reconstruction in a referral centre due to extensive bone loss after aseptic or septic revision of a hip or knee prosthesis were included in the study. Relevant case-related cost drivers of the aG-DRG matrix (including staff and material costs of the operating theatre area and the ward) were taken into account. The actual costs were determined according to the specifications of the calculation manual published by the German institute for the remuneration system in hospitals (InEK). For each case, the contribution margin was calculated by relating the hospital's internal costs to the corresponding cost pool of the aG-DRG matrix.According to the DRG system 2021, 17 different DRGs were used for billing - in 70% based on a patient clinical complexity level (PCCL) ≥4. Compared with the InEK calculation, there is a deficit of -2,901€ per case in the examined parameters. The costs of physicians show a shortfall in both the operating theatre and on the ward. Implant costs, which were supposed to be compensated by hospital-specific additional charges, show a hospital-specific shortage of -2,181€. When analysing the risk factors for cost recovery, only these showed a significant difference.Implantation of the megaendoprosthesis in revision arthroplasty is often the last option to preserve limb function. At present, despite a high degree of specialisation and process optimisation, this treatment cannot be provided cost-effectively even in tertiary care. The politically desired specialised department structure requires sufficient reimbursement for complex cases. The economic outcome of each treatment case is often unpredictable, however the surgeon is confronted with these cases and is expected to treat them. The high standard deviation indicates large differences in the cost/revenue situation of each individual case. Our results show for the first time a realistic cost analysis for megaprosthesis in revision arthroplasty and underline the importance of an adequate hospital-specific charge, individually agreed by the funding units. The calculation should include not only the implant costs, but also the increased staff costs (increased, complex planning effort, quality management, surgery time, etc.).

Skull base surgery in the German DRG system-New categorization of important procedures

Surgery of the skull base includes interventions between the nose or paranasal sinuses (anterior skull base) or ear/temporal bone (lateral skull base) and the intracranial space. As interventions at the anterior skull base almost exclusively involve complex pathologies in ademanding anatomical region, in many cases two experienced surgeons from different disciplines are required who should be experienced in operating together. The technical and time requirements are also considerable in many cases; however, for many procedures there are no specific skull base operational and procedural keys (OPS) codes that take the considerable personnel and structural effort into account. Achange in the diagnosis-related groups (DRG) system, implemented since the beginning of 2023, now adjusts the remuneration of the abovementioned effort for malignant pathologies of the anterior and lateral skull base. The reallocation of procedures 5‑015.0/1/3/4 and 5‑016.0/2/4/6 results in asignificant upgrade of anterior and lateral skull base surgery. Since the beginning of 2023 skull base surgery will no longer be charged under DRG D25C with a(former) relative weight of 1.893, but with DRG D25B with acurrent relative weight of 3.753 when acode of the aforementioned groups is used. Nevertheless, further adjustments are necessary, for example, in the available reconstructive steps in order to provide the Institute for the Remuneration System in Hospitals (InEK) with the most differentiated data possible on the procedural effort of the intervention and to achieve amore balanced distribution of the reimbursements of skull base surgery in the long term.

Προϋπολογισμός και Ανάλυση Κόστους Υπηρεσιών Υγείας στο Γενικό Νοσοκομείο Παπαγεωργίου: Προετοιμασία για το Νέο Σύστημα Πληρωμών DRG

The Budgeting and Cost Analysis Department of Papageorgiou General Hospital created a new tool that utilizes real-time data and feedback from all clinics and departments and produces accurate reporting. The purpose of this tool is to calculate and predict the cost of medical services in a Diagnosis Related Group (DRG) oriented integrated environment. Data processing through Cost/Profit Centers produces and updates key economic and operational indicators (e.g. material and drug consumption, the average duration of hospitalization), which set the framework for the evaluation of clinics’ efficiency and performance. The revenues and expenses of each clinic and the deviations concerning the budget are monitored monthly. The reimbursement of health services based on the DRG system, depending on the medical procedures performed at each clinic, is regarded as revenue. On the other hand, cost analysis involves direct costs, and indirect costs which shape the cost of accommodation of hospitalization per day, estimated by algorithms and specific weighting factors. Thus, the operating cost of each clinic is calculated and then compared against its corresponding revenues. Papageorgiou General Hospital aims and pursues the further development of this budget monitoring tool, which is developed on the actual core health services of each clinic respectively. Fair reimbursement can be secured if data is linked to a dynamic, regularly updated data processing tool, i.e. accurate cost analysis &amp; sourcing.

Does the disclosure of medical insurance information affect patients' willingness to adopt the diagnosis related groups system.

Medical insurance information disclosure is not only a direct way for the public to understand and master social insurance information and resource use benefits, but also an important way for the public to participate in medical service governance and supervision. Some studies have shown that information disclosure can significantly reduce the risk perception of user groups, strengthen their trust and reduce the negative impact of information asymmetry. Based on risk perception and trust perception theories, this paper focuses on the mechanisms influencing patients' attitudes in the process of implementing a Diagnosis Related Groups payment system. Using medical insurance information disclosure from a governance perspective as the research object, the impact of medical insurance information disclosure on patients' willingness to adopt the Diagnosis Related Groups payment system was analyzed by means of a questionnaire survey, Data analysis and hypothesis testing via SPSS while the mechanism of the impact of medical insurance information disclosure on patients' attitudes was explored in depth. It was found that medical insurance information disclosure had a significant positive effect on patients' trust perceptions and a significant negative effect on patients' risk perceptions. The more comprehensive information patients received, the stronger their trust and the lower their perceived risk. This paper conducts an empirical study from patients' perspective, broadens the scope of research on medical insurance Diagnosis related groups, enriches the application of risk perception and trust perception theories in the medical field, and provides management suggestions for medical institutions in the management of medical insurance information disclosure.

Another encroachment on our liberal profession-The German Federal Ministry of Health continues to stubbornly ignore the self-government

Overall, the German healthcare system is shaped by numerous players and institutions. With the state medical associations as public corporations for self-governance and the Heilberufsgesetz (German Health Professions Act), professional practice, professional representation and professional jurisdiction are regulated at the state level. The Joint Federal Committee ("Gemeinsame Bundesausschuss"), the highest decision-making body of joint self-governance in the German health care system, plays a central role. Practicing a liberal profession is intended to guarantee an undisturbed physician-patient relationship. Neither in hospitals nor in outpatient care can medical care be separated from economic constraints, but the fundamental binding of medical care to pure service catalogs leads to mismanagement. The goal of the hospital reform proposals currently being developed by the German Federal Ministry of Health is to avoid unnecessary hospital closures and to ensure high-quality care throughout the country, even in rural regions. In the age of strict separation of outpatient and inpatient care, the diagnosis-related group (DRG) system has primarily led to services migrating to the inpatient sector. It may no longer be possible to offer all continuing education courses at all continuing education centers following a reform of the care structure.

A Bibliometric Analysis of Diagnosis Related Groups from 2013 to 2022.

As an important management method of the global healthcare system, diagnosis related groups (DRGs) classify patients into different cost groups and pay more attention to the equitable distribution of medical resources and the quality of medical services. At present, most countries have used DRGs to help medical institutions and doctors to treat patients more accurately, avoid the waste of medical resources, and improve treatment efficiency. The Web of Science database was searched to collect all relevant literature on DRGs from 2013 to 2022. The literature information was imported into CiteSpace, Vosviewer, and Histcite for data analysis and visualization of the results. Analyze the cooperative relationship among the countries, institutions, journals, and authors. The usage trend of keywords; Highlight the content of the cited articles. The number of articles published in this decade was stable, and the number of citations in 2014 was the highest. The United States and Germany, as the first countries to use the DRGs system, are ahead of other countries in terms of the number and quality of articles. We have carried out content research on the articles with high citations, and summarized the application range of DRGs; classification method; advantages and disadvantages of the application. In general, the development trend of DRGs in foreign countries is to continuously optimize the classification method, expand the scope of application, and improve the application effect. These provide support and reference for the improvement of medical services and the perfection of the medical insurance system. The application of DRGs can improve the quality and efficiency of medical services, and reduce the waste of medical expenses. It can also promote the rational allocation of medical resources and the equity of medical services. In the future, DRGs will pay more attention to the personalized diagnosis and treatment and fine management of patients, and the sharing and standardization of medical data, to promote the development of medical informatization.

Implementation of Healthcare Financing Based on Diagnosis-related Group in Three WHO Regions; Western Pacific, South East Asia and Eastern Mediterranean: A Systematic Review

Payment methods based on a controlled or adjusted prospective payment system rather than ‘Fee for Services’ or direct payment are considered beneficial to access the healthcare delivery services. The purpose of this review was to identify technical challenges faced by three WHO regions, namely, Western Pacific, South East Asia Eastern and the Mediterranean while establishing or adopting a diagnosis-related group (DRG)/case-mix grouper and report the extent of implementing this system for reimbursement and healthcare financing in three WHO regions, namely, Western Pacific, South East Asia Eastern and the Mediterranean. The study followed PRISMA guidelines, and 33 articles published from 1st January 2009 to 31st December 2019 were selected for critical appraisal after systematic filtration. The objectives of the implementation of the DRG system in most developed and developing countries in these regions were to bring transparency in the payment system and reduce treatment costs by avoiding unnecessary healthcare services. The countries in the study regions were at different levels of economic and social development status, therefore the implementation and adaptation status of DRG/case-mix system/grouper varied in these countries The findings revealed that most of the countries faced challenges related to inequalities and inefficiencies in the healthcare system, shortage of funding, poor documentation related to diagnosis and procedures, incomplete medical record files and lack of primary data required for the case-mix system during the DRG/case-mix adaptation phase. The results also pointed to the importance of initial pilot testing of the DRG/case-mix system/grouper and careful manipulation and adaptation to the local context, especially when the DRG system/grouper imported from other countries.

Performance of a simplified nutrition screening tool for outpatient radiotherapy cancer patients.

Public hospitals in Thailand recently adopted a new nutrition screening tool to satisfy documentation requirements for reimbursements through the diagnosis-related group system. However, data on the performance of this instrument remains limited. This study was designed to assess the validity and cutoff points of the Society of Parenteral and Enteral Nutrition of Thailand (SPENT) nutrition screening tool against the patient-generated subjective global assessment (PG-SGA) and malnutrition diagnostic criteria proposed by the global leadership initiative on malnutrition (GLIM) in cancer patients receiving outpatient radiation therapy. A cross-sectional study of 350 patients was conducted from August 2018 to September 2020. All patients were screened for malnutrition using the SPENT nutrition screening tool. The instrument's sensitivity, specificity, positive predictive value, negative predictive value, and agreement were calculated using either the PG-SGA or GLIM malnutrition diagnosis as benchmarks. The cutoff that gave the highest sensitivity and specificity of the SPENT nutrition screening tool was selected. The mean age standard deviation of the 350 cancer patients was 59.9 (13.9) years, and 191 (54.6%) were men. Head and neck cancers were the most common type (35.7%). Against PG-SGA and GLIM malnutrition diagnosis, the SPENT nutrition screening tool demonstrated good sensitivity (85.3% and 82.8%), specificity (84.1% and 59.4%), positive predictive value (90.5% and 64.0%), negative predictive value (76.3% and 79.9%), with moderate strength of agreement (Cohen kappa 0.678, P < .001 and 0.414, P < .001). Using only the first 2 out of 4 questions revealed an acceptable sensitivity and specificity. The SPENT nutrition screening tool is an accurate, sensitive, and specific tool for malnutrition screening in cancer patients receiving outpatient radiotherapy.

Using exogenous organizational and regional hospital attributes to explain differences in case-mix adjusted hospital costs.

Diagnosis-related group (DRG) hospital reimbursement systems differentiate cases into cost-homogenous groups based on patient characteristics. However, exogenous organizational and regional factors can influence hospital costs beyond case-mix differences. Therefore, most countries using DRG systems incorporate adjustments for such factors into their reimbursement structure. This study investigates structural hospital attributes that explain differences in average case-mix adjusted hospital costs in Switzerland. Using rich patient and hospital-level data containing 4 million cases from 120 hospitals across 3 years, we show that a regression model using only five variables (number of discharges, ratio of emergency/ambulance admissions, rate of DRGs to patients, expected loss potential based on DRG mix, and location in large agglomeration) can explain more than half of the variance in average case-mix adjusted hospital costs, capture all cost variations across commonly differentiated hospital types (e.g., academic teaching hospitals, children's hospitals, birth centers, etc.), and is robust in cross-validations across several years (despite differing hospital samples). Based on our findings, we propose a simple practical approach to differentiate legitimate from inefficiency-related or unexplainable cost differences across hospitals and discuss the potential of such an approach as a transparent way to incorporate structural hospital differences into cost benchmarking and payment schemes.

The importance of good governance in hospital payment reform – A case study from Ukraine

In 2005, Ukraine embarked on hospital financing reforms that included the introduction of a Diagnosis Related Group (DRG) based payment system for acute inpatient care. The primary purpose of introducing activity-based funding was to provide incentives for hospitals to use their limited resources more efficiently.Following an extended period of preparation and planning during which technical assistance was provided by various development agencies, Ukraine took action to implement the DRG system at a national level in April 2018, through a World Bank project. While some progress was made, the execution of the reform faced challenges with the organisation and administration of the implementation process, and duplication of effort. The consequence of these shortcomings was that the newly introduced system was not capable of measuring inpatient DRG activity at a level of accuracy necessary for the determination of hospital performance and the subsequent calculation of payments.If the expected outcomes of DRG implementation in Ukraine are to be realised, stakeholders including both beneficiary agencies and development organisations, will need to improve program governance through better coordination of their activities towards a common goal.

The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis

PurposeThe aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA).MethodsA survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options.ResultsAlmost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects.ConclusionsThis survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.

Cost-utility analysis of early versus delayed endovascular intervention in critical limb-threatening ischemia patients with rest pain.

The prevalence of chronic limb-threatening ischemia (CLTI) and poor health outcomes are high in Germany. Serious consequences of CLTI such as amputation and mortality can be effectively prevented by the early use of evidence-based therapeutic measures such as endovascular intervention. We have developed a cost-utility analysis to compare endovascular intervention with bare metal stents (BMSs) and endovascular intervention after conservative treatment from the German payer perspective. A Markov model, with a 5-year time horizon and seven states, was developed: (1) intervention, (2) stable1, (3) major amputation, (4) reintervention, (5) stable2, (6) care, and (7) all-cause death. Transition probabilities were obtained by pooling the outcomes from multiple clinical studies. The costs were estimated using data from the German diagnosis-related group system, the German rehabilitation fund, and related literature. Health-state utilities were obtained from the reported data. The primary outcomes were the quality-adjusted life-years (QALYs) and costs. Early BMS intervention after 5years resulted in a cost of €23,913 and an increase of 2.5 QALYs per patient, and endovascular intervention with BMS after conservative treatment after 5years resulted in a cost of €18,323 and an increase of 2 QALYs per patient. The incremental cost-effectiveness ratio was €12,438. The number of major amputations was reduced by 6%. The results of the structural, deterministic, and probabilistic sensitivity analyses were robust. Early endovascular intervention with BMS resulted in more QALYs and a reduced risk of major amputation for early-stage CLTI patients. Our results showed that early endovascular intervention is very cost-effective according to World Health Organization recommended cost-effectiveness thresholds. However, the clinical decision regarding the use of early endovascular intervention should be determined by individual patient-level eligibility and the physician's judgment.