Diagnosis-related Groups System Research Articles

Integration of clinical pathway construction and hospital information system in intensive care unit is the core of digitalized hospital: experience of clinical pathway construction in Liuzhou Worker's Hospital from 2016 to 2018

To explore the effective strategies of clinical pathway construction in intensive care unit (ICU). From January 2016 to July 2018, 1 488 patients were discharged from ICU of Liuzhou Worker's Hospital of Guangxi Zhuang Autonomous Region. The pilot project of "postoperative monitoring of heart disease" with simpler route and less variation was selected first, and then the pilot project was promoted to "post-operative monitoring" after its success. The implementation of the clinical pathway was divided into three stages: the first stage, January 2016 to May 2017, for the pilot phase, a total of 87 patients were enrolled in the clinical pathway trial; the second stage, June 2017 to December 2017, surgical ICU "postoperative monitoring of heart disease" was put into the pathway 111 times; the third stage, January 2018 to July 2018, surgical ICU "postoperative monitoring of heart disease" was entered in the path 116 times; comprehensive ICU "postoperative care" was put into the path 96 times. After carefully analyzed the reasons and sum up the experience, internet+medical treatment (Liuzhou Worker's Hospital became the fifth deep partner of Tencent Inc in the internet+medical field, and carried out the plan and practice of "WeChat wisdom hospital 3.0" in 2017) was used, four aspects of connection, payment, security and ecological cooperation were upgraded, and the construction of 6 level of electronic medical record (EMR) was accelerated. At the same time, through diagnosis related groups system (DRGs), the concept of evidence-based medicine, quality management and continuous improvement as the leading factor, and combined with the construction status of hospital information system (HIS) and EMR system, step by step implementation and design of information management platform for clinical pathway were formulated. The completion rate of clinical pathway, average length of hospital stay, average cost, cure rate and improvement rate were the main observation parameters. In the first stage, none of the 87 patients who entered the clinical pathway completed the clinical pathway. In the second stage, the completion rate of surgical ICU clinical pathway was increased from 33.33% in June 2017 to 94.44% in December 2017, and up to 100% in October 2017, and the average completion rate from January to July 2018 was 94.00%. The completion rate of ICU clinical pathway was increased from 81.82% in January 2008 to 92.86% in July 2008. There was a significant difference in the overall clinical pathway completion rate from 2016 to 2018 (χ2 = 204.300, P = 0.000). After the effective implementation of clinical pathway in June 2017, the length of hospital stay of patients was significantly shortened as compared with that before implementation (days: 2.96±0.43 vs. 6.66±0.75, P < 0.01), and the daily cost was significantly reduced (Yuan: 3 550.92±755.51 vs. 6 171.48±377.29, P < 0.01). The average length of hospital stay was shortened by about 3.84 days (P < 0.01), and the average daily cost was reduced by about 2 108.39 Yuan (P < 0.01) after the implementation of clinical pathway by surgical ICU "postoperative monitoring of heart disease" as compared with those before implementation. The average length of hospital stay was shortened by about 2.98 days (P < 0.01) and the average daily cost was reduced by 5 094.13 Yuan (P < 0.01) after the implementation of clinical pathway by comprehensive ICU "post-operative monitoring" as compared with those before implementation. At the same time, the cure rate was increased from 1.16% (7/603) to 42.26% (105/227), and the improvement rate was decreased from 94.36% (569/603) to 52.86% (120/227, both P < 0.01) after the implementation of surgical ICU clinical pathway, but there was no significant difference in the cure rate or the improvement rate after the implementation of comprehensive ICU [2.77% (33/1 193) vs. 2.22% (2/90), 79.21% (945/1 193) vs. 97.78% (88/90), both P > 0.05]. Application of clinical pathway to control ICU quality and guide diagnosis and treatment, more refined diagnosis and treatment schemes including clinical guidelines, average length of stay, average cost of hospitalization, cost-efficiency ratio and so on were completed, which confirmed that the improvement of clinical pathway management strategy originated from clinical were needed. Informatization, intellectualization, standardization and effective control of medical cost of clinical pathway could improve medical quality and accurate management. The integration of ICU clinical pathway construction and HIS could promote the development of digital hospitals.

Using the Method of Medical Insurance Payment Reform to Promote the Path Selection of Large Hospital Development

At the beginning of the establishment of the basic medical insurance system in China, the primary implementation was a single project-based payment. At present, it has gradually explored a single or mixed way to pay, mainly including payment by disease type, payment by the number of people, payment by medical service unit and payment by the DRGs (Diagnosis Related Group System). This paper discusses the reform of payment mode of basic medical insurance in large hospitals and summarizes the main features of the reform of the payment mode of basic medical insurance in the past. First of all, the basic medical insurance management department has absolute choice and pricing power. The government is responsible for the management of basic medical insurance, and the hospital is in a state of passive implementation of government policies. In addition, the reasonable demands of large hospitals can hardly be effectively reflected in the policy. Last but not least, the improvement of hospital serviceability and the promotion of patients' reasonable medical treatment effect have not been realized effectively. The research results of this paper mainly discuss the reform path of basic medical insurance payment methods in large hospitals. For one thing, large hospitals can proactively report to the basic medical insurance management department the reformed disease types and disease charges for basic medical insurance payments. For another thing, the large hospitals can determine the diagnosis and treatment plan of the disease according to the clinical path of disease diagnosis and treatment. The basic medical insurance management department can explore the new path method of reforming the basic medical insurance payment method in large hospitals according to the reform idea of “the same disease insurance standards are consistent” and individual “differentiated self-payment. At the same time, it is recommended that the government use the professional management ability of commercial insurance companies to improve the performance of basic medical insurance by purchasing commercial insurance company services. Give play to the third-party role of commercial insurance companies to help alleviate the asymmetry of the hospital and patient medical information and the contradiction between doctors and patients.

The use of valuations of healthcare services in other countries (basic benefits basket) in the tariffing process

The Agency for Health Technology Assessment and Tariff System is national institution supervised by Minister of Health. Agency is an advisory body in the reimbursement process. One of the Agency’s roles is setting a tariff for publicly funded healthcare services. Determining the cost of medical services is one of the most important conditions for valuating these tariffs. As in most European countries, the system of financing in-patient care in Poland is based on the Diagnosis Related Group system (DRG). DRG systems were created to increase efficiency in the use of available resources, and consequently to improve the quality of medical care. In order to compare the method and level of financing healthcare services with their equivalent abroad, the Agency analyzes information from other countries, especially those with GDP per capita similar to that of Poland. The Agency searches for patient group classification methods, payment methods, the shape of services and all factors affecting the valuation of services. The article describes the Polish inpatient services system against the background of solutions functioning in the world. The pricing process was presented, with particular emphasis on the process of obtaining data on foreign tariffs and their impact on the construction and pricing of healthcare services in Poland.

Nonresponsiveness, Severity Auditing, and Upcoding Deterrence

In many countries, the diagnosis-related group system has been expanded to address patient severity. This paper highlights a fundamental drawback of any price refinement policy under adverse selection. Without auditing, no mechanism such that high-severity patients receive more intensive treatment than low-severity patients can ensure that providers are deterred from upcoding. In contrast, we show that splitting can be implemented if the regulator designs an auditing mechanism when the proportion of low-severity patients is sufficiently high. The optimal level of services increases with severity under conditions depending on the net social benefit function and on the cost function.

Using discrete choice model to elicit preference for health-care priority setting.

BACKGROUND:Regarding lack of resources in the health-care sector, prioritization of these resources is inevitable. The objective of the current study was to elicit public preference in prioritizing and allocating health resources using a discrete choice experiment technique, which is currently the most commonly applied method in this field of researches.METHODS:In this discrete choice study, five attributes were selected through interview with 25 health experts to elicit people preferences in Tehran (Iran) in 2017. Eighteen choice tasks were arranged within 3 blocks, and this would be achieved with a sample size of 579. Choice data were modeled using generalized estimating equation method and STATA 14 software.RESULTS:Five attributes including level of emergency, severity of disease, communicable, benefit from treatment, and age are the most important attributes in the prioritizing health resources from the expert's point of view. As well as among these attributes, communicable (odds ratio = 2.81) is the most important attributes from the public's point of view.CONCLUSION:The results of this study could be very useful for prioritizing resources which is one of the most challenging measurements of the health system. By identifying the importance of each patient's characteristic, patients can be categorized in groups with different priorities, as well as the diagnosis-related group system, based on which resources are allocated.

Does DRG funding encourage hospital specialization? Evidence from the Italian National Health Service.

The impact of diagnosis-related group (DRG)-based funding has been analyzed along a wide range of dimensions. Its effects on hospital specialization, however, have been investigated only sparsely. This paper examines such effects in the context of the Italian National Health Service, where decentralization has produced a significant degree of variation in funding arrangements. To this end, a 9-year panel data set covering 762 Italian public and private hospitals was analyzed using a finite mixture model approach. Hospital specialization was measured by the internal Herfindahl-Hirschman Index. Three variables were introduced as proxies for the choices made by Italian Regions with respect to the development and use of their DRG systems. The best finite mixture model identified three groups of hospitals, two of which sizeable. Of these, one included nearly all public hospitals, while the other was composed almost exclusively of small and medium-sized investor-owned hospitals. Averagely, private and smaller hospitals showed a stronger tendency to specialize over time. The positive impact of DRG funding on the hospitals' propensity to specialize found only limited empirical support. Moreover, it emerged as comparatively much smaller for public hospitals vis à vis private ones.

Economic Analysis in a Diagnosis Related Groups System for Two-stage Exchange of Prosthetic-joint Infections.

Background: There is a constant increase of joint arthroplasties performed, with an infectious risk of 1-2%. Different therapeutic options for prosthetic-joint infections exist, but surgery remains essential. With a two-stage exchange procedure, a success rate above 90% can be expected. Currently, there is no consensus regarding the optimal interval duration between explantation and reimplantation. This retrospective study aimed to assess the economic impact of a two-stage exchange from a single-hospital perspective.Methods: 21 patients who have undergone a two-stage exchange of a hip or knee prosthetic-joint infection at the University Hospital of Lausanne (Switzerland) from 2012 to 2013 were included. The revenues earned according to the Swiss Diagnosis Related Groups (SwissDRG) system introduced in 2012 and the costs were compared for each hospital stay.Results: The remuneration ranged from 26'806 to 42'978 Swiss francs (CHF) (~ 22'905-36'723 EUR, median 36'338 CHF, ~ 31'049 EUR). The median total cost per patient was 76'000 CHF (~ 65'000 EUR) (51'151 to 118'263; hip median 79'744, knee median 66'708). The main determinant of the costs was the length of the hospital stay. Revenues never covered all the costs, even with a short-interval procedure. The hospital lost a median of 35'000 CHF per patient (~ 30'000 EUR) (22'280 to 64'666).Conclusion: The current DRG system may not be specific enough for rewarding prosthetic-joint infections. Several options could be considered to act on the length of the hospital stay. In order to cover costs in complicated cases, such as prosthetic-joint infections, more specific DRGs are needed.

Problems and suggestions for the application of diagnosis-related groups system in burn surgery

The diagnostic codes of diagnosis-related groups system used in our country are different from the clinical diagnostic criteria of burns. The author suggests that the diagnostic codes should be improved according to clinical criteria in terms of the total area and depth of burns and inhalation injury, and the diagnosis of burns with related special causes and sites should be added to the clinical criteria.

Costs and proceeds from patients admitted via the emergency room with mild craniocerebral trauma

The introduction of the diagnosis-related groups (DRG) in 2003 radically changed the billing of the treatment costs. From the very beginning, trauma surgeons questioned whether the introduction of the DRG could have a negative impact on the care of the severely injured. "Trauma centers in need" was the big catchword warning against shortfalls at trauma centers due to the billing via DRG. This situation was confirmed in the first publications after introduction of the DRG, showing a clearly deficient level of care of polytrauma cases. Over the years, adjustments have led to an improvement in the remuneration for polytraumatized patients. In the emergency room, polytrauma is not always the final diagnosis. Aconsiderable proportion of patients are only slightly injured, but must be admitted via the emergency room due to the circumstances of the accident or suspected diagnosis at the scene of the accident to exclude life-threatening injuries. In this study, patients with the billing diagnosis of mild craniocerebral trauma were selected as an example. The proportion of these patients was 22% during the period of observation in 2017. For these patients, the proportional costs during treatment were calculated. It could be shown that 60.36% of the costs during a 2‑day treatment of these patients were incurred in the emergency room. Costs for material and personnel could not be considered. Despite not including these expenses, the costs were never covered for any of these patients. For patients with slight injuries after trauma management in the emergency room, the present adjustments to the DRG system by increasing the basic case value seem to be insufficient. Additional remuneration for these patients seems absolutely justified to further ensure adequate quality of care.

PDB45 - COSTS OF PREVENTION, MONITORING AND TREATMENT OF IODINE DEFICIENCY DISORDERS IN GERMANY

Iodine deficiency can lead to impaired thyroid function and other so called iodine deficiency disorders (IDD). In Germany, more than 30 percent of the population is considered to be mildly to moderately iodine deficient. The economic burden of IDD management is still unclear. The purpose of our study was to compile costs for prevention, monitoring and treatment of IDDs in Germany. We assessed costs for the medical management of IDDs from the German societal perspective (index year 2018). Resource utilization was based on published evidence. Outpatient costs were based on the ‘Uniform Value Scale of the National Association of Statutory Health Insurance Physicians ' and the ‘German Medical Fee Index'. Inpatient costs were based on the 'case fees' of the German Diagnosis Related Groups System. Medication costs are calculated according to reimbursement rules. Indirect costs were based on productivity loss occurring due to disease-related absence from work. Published data and additional expert opinion were used to estimate resource utilization and costs for IDD prevention and monitoring. Annual average costs per case were EUR 20,792 for intellectual disability; EUR 2,541 for goiter and/or benign thyroid nodules; EUR 4,204 for hyperthyroidism; EUR 2,549 for hypothyroidism; and EUR 10,624 for thyroid cancer. Average costs for miscarriage were EUR 2,182The annual per-person costs in the German population for an IDD prevention program including costs for monitoring, salt iodization, information campaigns and administering and enforcing an iodine fortification program were approximately EUR 0.10. Cost for the management of disorders related to iodine deficiency range from EUR 2,182 per case to EUR 20,792 annually. In contrast, prevention costs are low. For recommendations regarding the implementation of an IDD prevention program, effectiveness and epidemiological data needs to be considered in addition in a full economic evaluation, for example, by applying a decision-analytic model.

Comparing hospital compensation to actual costs based on the Greek Diagnosis-Related Group system in ophthalmology.

The purpose of this study is to evaluate the effects of the new system of pricing medical services in the field of ophthalmology in Greece. In addition, it attempts to benchmark the system with respective interventions at an international level. The study deals with the implementation of the new system, presenting systematic pairing of ophthalmic coding with other coded information regarding registration and management. Statistical data analysis is performed related to the cost and, finally, proposals are formulated to improve the current system. A significant difference is noted in the quantitative and qualitative characteristics of the Greek system compared with internationally applied Diagnosis-Related Group (DRG) systems in the field of ophthalmology. The proposed funding for ophthalmic inpatient cases mostly meets real needs and costs of hospitals for supplies. Complicated cases, mainly in cataract surgery, increase the real cost and may cause a deviation depending on the rate of complications. In these cases, the average cost was 673.28 ± 58.7&OV0556; as opposed to uncomplicated cases (346.78 ± 21.3&OV0556;), bearing a statistically significant difference (P < 0.001, Mann-Whitney test). The total compensation of the hospital was higher than the actual cost for surgical procedures covering the respective expenses. Although the recently implemented compensation system for public hospitals mostly covers the actual cost for ophthalmic surgical cases, some deviations from the real needs are being identified. Several amendments could be applied to increase efficiency and improve the quality of health services provided by Greek hospitals.

Total laparoscopic hysterectomy: how does training for surgeons in a standardized operation affect hospitals and patients?

Surgical training usually means inexperienced physicians initially doing operations supervised by an experienced physician, to gain the experience and skills needed to conduct surgery independently. Various issues arise here for both hospitals and patients. Are training procedures associated with higher complication rates, blood losses, and transfusion rates? What does training in the operating room ultimately cost in terms of valuable surgical time? Do longer hospitalization periods potentially mean financial losses for the hospital under the diagnosis-related groups (DRG) system? A retrospective analysis was carried out of data for 571 patients who underwent total laparoscopic hysterectomy (TLH) in the Department of Gynecology at the University of Erlangen from 2009 to 2012, with/without adnexectomy, due to benign indication; and of data for 255 patients who underwent the same procedures in Karlsruhe Municipal Hospital in 2013-2014. The patients were classified into two groups: those in whom surgery was carried out by experienced specialists who had carried out at least 40 independent operations; and those in whom it was carried out by a trainee resident who had personally done fewer than 40 operations. In the two groups, the patients had similar mean body mass indexes, uterus weights, and blood losses. Patients in the specialist group were slightly older. There were no differences in complication rates. Over two-thirds of complications occurred in patients with previous surgery. Procedures by residents took significantly longer. Hospitalization periods in both groups were still below the mean threshold length of stay under Germany's DRG system, so that no income losses occurred even with training procedures. Training and teaching operations supervised by experienced surgeons are just as safe as operations by experienced surgeons themselves. Interpretation of these data is of course limited by the retrospective study design; patients treated by specialists tended to have more prior operations and were older, with a trend toward larger uteri. Surgical training, as the example of TLH in benign indication shows here, involves an additional time of approximately 10-20min per operation. With regard to the revenue situation, the hospitalization periods in both groups were within the profit zone for the hospital concerned.

Economic assessment of the use of the sFlt-1/PlGF ratio test to predict preeclampsia in Germany

BackgroundThe PRediction of short-term Outcome in preGNant wOmen with Suspected preeclampsIa Study (PROGNOSIS) demonstrated that a soluble fms-like tyrosine kinase 1/placental growth factor (sFlt-1/PlGF) ratio ≤ 38 ruled out the occurrence of preeclampsia in the next week with a negative predictive value of 99.3%; a ratio > 38 indicates an increased risk of developing preeclampsia in the next 4 weeks. We performed an assessment of the economic impact of the sFlt-1/PlGF ratio test for short-term prediction of preeclampsia in Germany.MethodsWe adapted a cost-effectiveness model, which had been developed to estimate the incremental value of adding the sFlt-1/PlGF ratio test with a cut-off ratio of 38 to standard diagnostic procedures for guiding the management of women with suspected preeclampsia in the UK. We used the adapted model to estimate the incremental value of the sFlt-1/PlGF ratio test (cut-off 38) for guiding the management of women with suspected preeclampsia from a German Diagnosis-Related Group (DRG) payer perspective. The economic model estimated costs associated with diagnosis and management of preeclampsia in women managed in either a ‘no-test’ scenario in which clinical decisions are based on standard diagnostic procedures alone, or a ‘test’ scenario in which the sFlt-1/PlGF test is used in addition to standard diagnostic procedures. Test characteristics and rates of hospitalization were derived from patient-level data from PROGNOSIS. The main outcome measure from the economic model was the total cost per patient.ResultsIn the model adapted to the German DRG payer system, introduction of the sFlt-1/PlGF ratio test with a cut-off value of 38 could reduce the proportion of women hospitalized in Germany from 44.6 to 24.0%, resulting in an expected cost saving of €361 per patient.ConclusionsThe sFlt-1/PlGF ratio test is likely to reduce unnecessary hospitalization of women with a low risk of developing preeclampsia, and identify those at high risk to ensure appropriate management. Even within the restrictions of the DRG system in Germany, this results in substantial cost savings for women with suspected preeclampsia.

Opening the black box of diagnosis-related groups (DRGs): unpacking the technical remuneration structure of the Dutch DRG system

While we know that upcoding of diagnosis-related groups (DRGs) regularly occurs, we have little knowledge of the role of the technical features of coding systems in inducing coding behaviour. This paper presents methods for investigating the financial structure of the Dutch DRG system, and more in particular the grouper software, to gain such insight. The paper describes a system for investigating the robustness of the reward structure, by simulating the response of the DRG system to small changes in individual coding. The results from these analyses are used to visualise some data on coding behaviour, and to investigate how this behaviour is affected by incentives in the technical features of the DRG system. A number of technical weaknesses in the system are also identified.

Center formation, registries, and quality assurance : Economic impact on training and quality of care

The increasing tendency toward formation of centers and expansion of quality assurance has had a clear effect on medical education and quality of care in Germany in recent years. On the background of the German diagnosis-related groups (DRG) system and the significant devaluation of DRG codes, this issue should be addressed, particularly in the field of orthopedic endoprostheses. The effects of center formation and quality assurance on education and quality of care were evaluated based on a middle-sized clinic. In particular, we highlighted the number of training interventions in recent years on the background of the EndoCert initiative. The costs of complete certification of a hospital according to the KTQ or ISO standard, the expenses for the EndoCert certifications and the EPRD, as well as the continuously increasing personnel demands for registries, quality assurance, and education centers represent an immense economic burden. An improvement in the quality of care can be assumed for the EndoCert Initiative, but this remains without consequence for the revenues situation of the respective cases. In light of the lack of medical students and in terms of the quality of care in Germany, it must be discussed as to what extent a training-adapted remuneration of clinics is possible. We stress that medical training doesn't only take place in the operating theater and, up until now, has often not been awarded a high priority in the everyday practice of middle-sized clinics across Germany. Since refinancing is not available in the DRG system, in the absence of remuneration of medical education and the different medical center systems, we can expect that affected clinics, particularly those under economic strain, will no longer be able to meet the high demands of modern initiatives.

Caesarean Section Rates and Activity-Based Funding in Northern Norway: A Model-Based Study Using the World Health Organization's Recommendation.

Objective Caesarean section (CS) rates vary significantly worldwide. The World Health Organization (WHO) has recommended a maximum CS rate of 15%. Norwegian hospitals are paid per CS (activity-based funding), employing the diagnosis-related group (DRG) system. We aimed to document how financial incentives can be affected by reduced CS rates, according to the WHO's recommendation. Methods We employed a model-based analysis and included the 2016 data from the Norwegian Patient Registry (NPR) and the Medical Birth Registry of Norway (MBRN). The vaginal birth rate and CS rates of each hospital trust in Northern Norway were analyzed. Results There were 4,860 deliveries and a 17.5% CS rate (range 13.9–20.3%). The total funding of the deliveries was €16,351,335 (CS: €6,389,323; vaginal births: €9,962,012). The CS rate varied significantly and was lower in the southern region (P < 0.002). Consequently, the introduction of a cutoff at a 15% CS rate would gain the two southern hospital trusts by a budget increase of 0.2%. The two northern ones would experience 6.4% less resources. A total of €644,655 could be allocated to further quality and safety initiatives in obstetrics. Conclusion The economic consequences of the model-based financial incentive were low, but probably sufficient to get the necessary attention and influence on the CS rate. Recommendations A financial incentive for the reduction of CS rates should be tested as a supplement to other instruments.

Cost analysis of await-and-see strategy after radiochemotherapy in distal rectal cancer.

Nonoperative management (NOM) of rectal cancer after radiochemotherapy (RtChx) in patients with aclinical complete response is an emerging strategy with the goal to improve quality of life without compromising cure rates. However close monitoring with both magnetic resonance imaging (MRI) and rectoscopy is required for the early detection of possible local regrowths. We therefore performed acost analysis comparing the costs of immediate surgery with the costs for MRI and rectoscopy during surveillance as in the upcoming CAO/ARO/AIO-16 trial. MRIs and rectoscopies of patients with aclinical complete response after RtChx over the course of 5years were simulated and compared with immediate surgery after RtChx. Transition probabilities between health stages (no evidence of disease, local regrowth and salvage surgery, distant failure) were derived from the literature. Costs for ambulatory imaging and endoscopic studies were calculated according to the "Gebührenordnung für Ärzte" (GOÄ), costs for surgery based on the diagnosis-related groups system. Three different scenarios with higher costs for salvage surgery or higher regrowth rates were simulated. Apatient without disease recurrence will generate costs for MRI and rectoscopy of 6344 € over 5years compared with costs of 14,511€ for immediate radical surgery. When 25% local regrowths with subsequent salvage surgery were included in the model, the average costs per patient are 8299 €. In our simulations aNOM strategy was cost-saving compared with immediate surgery in all three scenarios. ANOM strategy with an intensive surveillance using MRI and rectoscopy will produce costs that are expected to remain below those of immediate surgery.

Redefining diagnosis-related groups (DRGs) for palliative care \u2013 a cross-sectional study in two German centres

BackgroundHospital costs and cost drivers in palliative care are poorly analysed. It remains unknown whether current German Diagnosis-Related Groups, mainly relying on main diagnosis or procedure, reproduce costs adequately. The aim of this study was therefore to analyse costs and reimbursement for inpatient palliative care and to identify relevant cost drivers.MethodsTwo-center, standardised micro-costing approach with patient-level cost calculations and analysis of the reimbursement situation for patients receiving palliative care at two German hospitals (7/2012–12/2013). Data were analysed for the total group receiving hospital care covering, but not exclusively, palliative care (group A) and the subgroup receiving palliative care only (group B). Patient and care characteristics predictive of inpatient costs of palliative care were derived by generalised linear models and investigated by classification and regression tree analysis.ResultsBetween 7/2012 and 12/2013, 2151 patients received care in the two hospitals including, but not exclusively, on the PCUs (group A). In 2013, 784 patients received care on the two PCUs only (group B). Mean total costs per case were € 7392 (SD 7897) (group A) and € 5763 (SD 3664) (group B), mean total reimbursement per case € 5155 (SD 6347) (group A) and € 4278 (SD 2194) (group B). For group A/B on the ward, 58%/67% of the overall costs and 48%/53%, 65%/82% and 64%/72% of costs for nursing, physicians and infrastructure were reimbursed, respectively. Main diagnosis did not significantly influence costs. However, duration of palliative care and total length of stay were (related to the cost calculation method) identified as significant cost drivers.ConclusionsRelated to the cost calculation method, total length of stay and duration of palliative care were identified as significant cost drivers. In contrast, main diagnosis did not reflect costs. In addition, results show that reimbursement within the German Diagnosis-Related Groups system does not reproduce the costs adequately, but causes a financing gap for inpatient palliative care.

Economy of Standards: European Association of Urology Guideline Changes Influence Treatment Costs in Stage I Testicular Cancer Patients

Objective: The study aimed to calculate direct medical costs (DMC) during the first year of diagnosis and to evaluate the impact of guideline changes on treatment costs in clinical stage (CS) I testicular germ cell tumor (TGCT) patients in a German healthcare system. Materials and Methods: Healthcare expenditures as DMC during the first year of diagnosis for 307 TGCT patients in CS I treated at our institution from 1987 to 2013 were calculated from the statutory health insurance perspective using patient level data. Three periods were defined referring to the first European Association of Urology (EAU) guideline in 2001 as well as to subsequent major guideline changes in 2005 and 2010. Data source for cost calculations were the German Diagnosis Related Groups system for inpatient stays (version 2014) and the German system for reimbursement of outpatient care (EBM – Einheitlicher Bewertungsmaßstab, edition 2014). Results: During our 25 years of study period, mean DMC in the first year after diagnosis for the entire cohort of TGCT patients in CS I almost halved from EUR 13.000 to EUR 6.900 (p < 0.001). From 1987 to 2001, DMC for CS I seminomatous germ cell tumor (SGCT) patients were EUR 13.790 ± 4.700. From 2002 to 2010, mean costs were EUR 10.900 ± 5.990, and from 2011 to 2013, mean costs were EUR 5.190 ± 3.700. For CS I non-seminomatous germ cell tumor (NSGCT) patients, from 1987 to 2001, mean DMC were EUR 11.650 ± 5.690. From 2002 to 2010, mean costs were EUR 11.230 ± 5.990, and from 2011 to 2013, mean costs were EUR 11.170 ± 7.390. Follow-up examinations became less frequent over time, which caused a significant cost reduction for NSGCT (p = 0.042) while costs remained stable for SGCT. When adding costs of relapse treatment, active surveillance (AS) was the most cost-effective adjuvant treatment option in CS I NSGCT whereas one course carboplatin or AS caused similar expenditures in SGCT patients. Conclusion: The introduction of the EAU guidelines in 2001 caused a decrease in DMC in CS I seminoma patients. This cost reduction mainly took place due to the declining importance of radiation therapy. No substantial changes were seen in patients with CS I NSGCT. Costs for follow-up care also diminished, but to a lesser degree. Even when considering expenditures for relapse treatment, AS remained cost-effective in CS I TCGT patients. Our data show that evidence-based medicine in TGCT can reduce DMC in the first year after diagnosis.

Different risk scores consider different types of risks: the deficiencies of the 2015 ESPEN consensus on diagnostic criteria for malnutrition.

In 2015, an European Society for the Parenteral and Enteral Nutrition malnutrition diagnosis consensus was published to unify the definition and simplify the diagnostic procedure of malnutrition, in which 'nutritional risk', 'malnutrition risk' and 'at risk of malnutrition' were referred to several times, and 'at risk of malnutrition' was encouraged to be coded and reimbursed in the International Classification of Diseases and diagnosis-related group system systems. However, there may be some mistakes when using the concepts of different 'risk' mentioned above. In this study, we aimed to explain different 'risks' using the original concept by different screening tools to clarify the definition and provide a recommendation for nutritional screening.