Diagnosis-related Groups System Research Articles

Pain - a neglected neurological issue

Chronic pain represents a great challenge; according to epidemiological data increasing numbers of patients should be expected. Based on recent advances, a better understanding of the pathophysiology of chronic pain has been achieved and neurologists have made a major contribution to this understanding. Chronic pain is accompanied by substantial maladaptive plastic alterations in both the peripheral and central nervous systems; therefore, neurological knowledge is of paramount importance for pain therapists but this contrasts with the current treatment situation of pain patients in Germany. There are basically too few departments and practices undertaking treatment, and neurologists are an exception in most pain centers. Furthermore, due to economic reasons neurological hospitals are currently experiencing a dearth of inpatients suffering from chronic pain. Diagnostic and/or treatment procedures for neurological pain entities (e.g. headaches or neuropathic pain) are insufficiently represented in the German diagnosis-related groups (DRG) reimbursement system and the obstacles for an efficient pain therapy in neurological practices are too high. Finally, there are too few academic positions for pain medicine in neurological hospitals; therefore, career opportunities for motivated young neurologists with an interest in pain are lacking. In order to address the unmet therapeutic needs of patients with chronic pain there is a high demand for (i) establishment of departments for neurological pain medicine, (ii) modification of the German DRG system and (iii) education of young neurologists with expertise in pain. Pain medicine in particular should be especially appealing to neurologists .

Impact of a diagnosis-related group payment system on cesarean section in Korea

Cesarean sections (CSs) are the most expensive method of delivery, which may affect the physician's choice of treatment when providing health services to patients. We investigated the effects of the diagnosis-related group (DRG)-based payment system on CSs in Korea. We used National Health Insurance claim data from 2011 to 2014, which included 1,289,989 delivery cases at 674 hospitals. We used a generalized estimating equation model to evaluate the association between the likelihood of cesarean delivery and the length of the DRG adoption period. A total of 477,309 (37.0%) delivery cases were performed by CSs. We found that a longer DRG adoption period was associated with a lower odds ratio of CSs (odds ratio [OR]: 0.997, 95% CI: 0.996–0.998). In addition, a longer DRG adoption period was associated with a lower odds ratio for CSs in hospitals that had voluntarily adopted the DRG system. Similar results were also observed for urban hospitals, primiparas, and those under 28 years old and over 33 years old. Our results suggest that the change in the reimbursement system was associated with a low likelihood of CSs. The impact of DRG adoption on cesarean delivery can also be expected to increase with time, as our finding provides evidence that the reimbursement system is associated with the health provider's decision to provide health services for patients.

Hospital manipulations in the DRG system: a systematic scoping review

Background: In the Diagnosis Related Group (DRG) payment system, hospitals are usually suspected of 'DRG creep,' which has been narrowly regarded as reporting diagnostic and procedural codes that result in larger reimbursement. Objective: This review was aimed to systematically explore ways in which hospital manipulations of DRG coding may occur. Methods: A systematic scoping review was conducted using MEDLINE, EMBASE, Web of Science, EconLIT, Proquest Digital Dissertation and Theses, Conference Proceedings, and Thai Index Medicus, using appropriate search strategies. Based on predefined criteria, each article abstract was screened by two screeners with good inter-rater reliability. The included articles were qualitatively explored using thematic content analysis. Results: Hospital manipulations of the DRG system can be categorized into three groups: corporate, clinical, and coding practices. Corporate includes all activities not directly related to patient care; possible manipulations are focused on hospital management, administration, or finance and therefore are the responsibility of the executive board or hospital director. Clinical manipulation deals with activities in the care process and is the responsibility of health care professionals. The last group covers conventional definition of DRG creep that focuses on documentation and coding. Conclusion: Hospital managers who deal with the DRG payment system should be aware that DRG creep is not merely about upcoding. Indeed, the DRG system can be manipulated by hospitals in three different approaches, the so-called 3C: corporate, clinical, and coding practices. Keywords: Diagnosis related group, DRG creep, hospital coding practice, upcoding, provider payment

Hospital financing in 2016. Relevant changes for rheumatology

Hospital financing 2016 will be influenced by the prospects of the approaching considerable changes. It is assumed that the following years will lead to aconsiderable reallocation of financial resources between hospitals. While not directly targeted by new regulations, reallocations always also affect specialties like rheumatology. Compared to the alterations in the legislative framework the financial effects of the yearly adaptation of the German diagnosis-related groups system are subordinate. Only by comprehensive consideration of current and expected changes aforward-looking and sustainable strategy can be developed. The following article presents the relevant changes and discusses the consequences for hospitals specialized in rheumatology.

Impact of Policies on the Rise in Sepsis Incidence, 2000-2010.

Sepsis hospitalizations have increased dramatically in the last decade. It is unclear whether this represents an actual rise in sepsis illness or improved capture by coding. We evaluated the impact of Centers of Medicare and Medicaid Services (CMS) guidance after newly introduced sepsis codes and medical severity diagnosis-related group (MS-DRG) systems on sepsis trends. In this retrospective cohort study of California hospitalizations from January 2000 to December 2010, sepsis was identified by International Classification of Diseases, Ninth Revision (ICD-9) coding (Dombrovskiy method). Sepsis-associated mortality rates were calculated. Logistic regression models evaluated variables associated with sepsis and mortality. Segmented regression time series analysis assessed changes in sepsis frequency for (1) baseline (January 2000 to September 2003); (2) post-CMS guidelines on sepsis coding (October 2003 to September 2007); and (3) after the introduction of MS-DRG (October 2007 to December 2010). Annual hospitalizations with sepsis diagnoses tripled within a decade, from 21.1 to 59.9 cases per 1000 admissions, with a 2.8- and 2.0-fold increase in severe and nonsevere sepsis, respectively, whereas annual admissions remained unchanged and sepsis-associated mortality decreased. Greatest increases were seen for severe sepsis present on admission (3.8-fold increase). Increases in sepsis were temporally correlated with CMS coding guidance and MS-DRG introduction after adjustment for comorbidity and other factors. Sepsis rate increases were associated with introduction of CMS-issued guidance for new sepsis ICD-9 coding and MS-DRGs. Coding artifact ("up-capture" of less severely ill septic patients) may be contributing to the apparent rise in sepsis incidence and decline in mortality. Epidemiologic trends based on administrative data should account for policy-related effects.

The DRG-Based Hospital Prospective Payment System in Greece: An Assessment of the Reimbursement Rates Using Clinical Severity Classification

Introduction: Diagnosis Related Groups (DRGs) are used throughout the health care industry to address issues of cost, effectiveness and quality of care. Nonetheless, many have argued that the DRGs do not adequately adjust for patient severity and this prospective payment system leads to reimbursement inequities. Objective: The purpose of this study is first, to explore the relationship between KEN-DRGs reimbursement rates (along with other controls) and clinical severity classification and second, to draw hospital reimbursement policy implications. Methods: The present study is a retrospective observational study, undertaken in a very large number of hospitalization cases and conducted exclusively by examining reimbursement administrative data collected from the e-DAPY database of National Organization for Provision of Healthcare Services (EOPYY) in Greece. The database provided contained all impatient hospitalizations classified for every single KEN-DRG code and for every MDC (aggregated) for the time period January to June 2013 (first semester of 2013). Results: Our results demonstrate that though there is a strong association between reimbursement rates and clinical severity, there are several KEN-DRG codes that are over-(under-) reimbursed, taking in consideration their clinical severity class. Conclusion: Because DRGs systems are crucial in measuring relative efficiency among hospitals, as well as driving ongoing reimbursement, they should incorporate and establish the severity level for every admission, so as to determine whether case mix growth is associated with real costs or with coding and documentation improvements at the hospital.

Procalcitonin: a valuable markerfor assessment of the success of antimicrobial therapy for severe sepsis An analysis using routine clinical data

Introduction and Objectives Procalcitonin (PCT), a precursor of the hormone calcitonin, is produced byC cells inthe thyroid. PCT is consistently produced duringsevere bacterial infections,causing its levels to increase [1,2].However,increased PCT levels are alsocharacteristic of other disease states, such as calcitonin-producing tumors, medullary C-cell carcinoma of the thyroid, acute respiratory distress syndrome,and invasive fungal infections. In particular,extensive clinical evidence indicates that PCT is a biomarker for both follow-up and evaluation ofthe effectiveness of antibiotic therapyfor severe respiratory infections and sepsis; in all relevant guidelines, the use of PCT in this contextis categorized asevidence class 2B or 2C [3,4]. For example, PCT levels differentiatemore effectivelybetween sepsis and systemic inflammatory response syndrome (SIRS)than those ofIL-6, IL-8, or CRP[5,6]. A meta-analysis of several clinical studiesofvarious infections demonstrated that PCT-guided antibiotic therapyreduced both therapy duration and the length of stay in intensive care [7].Based on this broad evidence, another meta-analysis focused on sepsiswas conducted, the results of whichindicatedthat antibiotic therapy can be curtailed by a mean of four days, and length of ICU stay reduced by a meanof 1.8 days. Based on existing algorithms,we determinedasequence of PCT measurementsappropriateto guide the use ofantibiotic therapy. In addition,rules for when therapy should commence and end, and cut off values to evaluate successful treatment have been established. Implementation of this system may introduce savings for the German diagnosis-related group(G-DRG) system [8]. A fall in PCT levelsby 80% compared withthe highest value, or to 0.25 ng/ml, indicatesuccessful antibiotic therapy. Hochreiter and Schroder showed that,in the case of adequate antibiotic therapy,PCT levels decreasesignificantly after 4 days [9]. In addition, Charles et al. demonstrated that a lack of PCT reduction on day 3,compared withday 2, of antibiotic therapyis a resilient indicator of inadequate treatment (OR = 10.29) [10]. Once guidelines and algorithms have been established for some time, the question of how well they are implemented in practice in theclinic arises.

Does Korea's current diagnosis-related group-based reimbursement system appropriately classify appendectomy patients?

PurposeAs several years have passed since the implementation of the Korean diagnosis-related group (DRG) payment system for appendicitis, its early outcomes should be assessed to determine if further improvements are warranted.MethodsWe retrospectively analyzed clinical data from Korean patients who underwent appendectomy, dividing the sample into 2 groups of those who received services before and after implementation of the DRG system. Based on the DRG code classification, patient data were collected including the amount of DRG reimbursement and the total in-patient costs. We subsequently performed univariate and multivariate analyses to identify independent factors contributing to higher total in-patient cost.ResultsAlthough implementation of the DRG system for appendicitis significantly reduced postoperative length of stay (2.8 ± 1.0 days vs. 3.4 ± 1.9 days, P < 0.001), it did not reduce total in-hospital cost. The independent factors related to total inhospital cost included patient age of 70 years or more (odds ratio [OR], 3.214; 95% confidence interval [CI], 1.769–5.840; P < 0.001) and operation time longer than 100 minutes (OR, 3.690; 95% CI, 2.007–6.599, P < 0.001). In addition, older patients (≥70 years) showed a nearly 10 times greater relative risk for having a comorbid condition (95% CI, 5.141–20.214; P < 0.001) and a 3.255 times greater relative risk for having higher total in-hospital cost (95% CI, 1.731–6.119, P < 0.001).ConclusionIt appears that older patients (>70 years) have greater comorbidities, which contribute to higher inpatient costs. Thus, our study suggests that patient age be considered as a DRG classification variable.

Early results of pediatric appendicitis after adoption of diagnosis-related group-based payment system in South Korea

PurposeAs an alternative to the existing fee-for-service (FFS) system, a diagnosis-related group (DRG)-based payment system has been suggested. The aim of this study was to investigate the early results of pediatric appendicitis treatment under the DRG system, focusing on health care expenditure and quality of health care services.Patients and methodsThe medical records of 60 patients, 30 patients before (FFS group), and 30 patients after adoption of the DRG system (DRG), were reviewed retrospectively.ResultsMean hospital stay was shortened, but the complication and readmission rates did not worsen in the DRG. Overall health care expenditure and self-payment decreased from Korean Won (KRW) 2,499,935 and KRW 985,540, respectively, in the FFS group to KRW 2,386,552 and KRW 492,920, respectively, in the DRG. The insurer’s payment increased from KRW 1,514,395 in the FFS group to KRW 1,893,632 in the DRG. For patients in the DRG, calculation by the DRG system yielded greater overall expenditure (KRW 2,020,209 vs KRW 2,386,552) but lower self-payment (KRW 577,803 vs KRW 492,920) than calculation by the FFS system.ConclusionThe DRG system worked well in pediatric patients with acute appendicitis in terms of cost-effectiveness over the short term. The gradual burden on the national health insurance fund should be taken into consideration.

Diagnosis-related Groups and Hospital Inpatient Federal Reimbursement.

To understand the complex system of reimbursement for health care services, it is helpful to have a working knowledge of the historic context of diagnosis-related groups (DRGs), as well as their utility and increasing relevance. Congress implemented the DRG system in 1983 in response to rapidly increasing health care costs. The DRG system was designed to control hospital reimbursements by replacing retrospective payments with prospective payments for hospital charges. This article explains how these payments are calculated. Every inpatient admission is classified into one of several hundred DRGs that are based on the diagnosis, complications, and comorbidities. The Centers for Medicare & Medicaid Services (CMS) assigns each DRG a weight that the CMS uses in conjunction with hospital-specific data to determine reimbursement. A population's DRGs represent the resources needed to treat the medical disorders of that population. Hospital administrators use this information to budget and plan for the future. The Affordable Care Act and other recent legislation affect medical reimbursement by altering the DRG system. Radiologic procedures in particular are affected. This legislation will give DRGs an even larger role in determining reimbursements in the coming years.

Effects of malnutrition on complication rates, length of hospital stay, and revenue in elective surgical patients in the G-DRG-system

ObjectiveMalnutrition is known to independently affect patient outcomes. The aim of this study was to investigate the prevalence of patients at risk for malnutrition in an elective surgery patient cohort and to analyze the effects of malnutrition on morbidity, mortality, and hospital length of hospital (LOS). Furthermore, we aimed to evaluate the economic effect of a diligent coding of malnutrition, as a side diagnosis, in a simulation of the German Diagnosis-Related Group system. MethodsThe nutritional status of 1244 patients undergoing elective surgery was standardized on the day of admission by the Nutritional Risk Screening (NRS) 2002. To quantify the influence of malnutrition on revenue, the real DRGs of all patients were grouped. In simulation, an appropriate International Classification of Diseases code was used as a secondary diagnosis for all malnourished patients based on the NRS rating. A multivariate logistic regression analysis and a Cox regression were performed to identify potential confounders and to determine the adjusted effect of nutritional status on the occurrence of complications and hospital LOS. ResultsThe prevalence of patients at risk for malnutrition (NRS ≥3) was 24.1% (300 of 1244). These patients showed a significant increase in hospital LOS (13 versus 7 d). Additionally, postoperative complications were significantly higher in this group (7.23% versus 6.91%). Including malnutrition in the Diagnosis-Related Group coding system resulted in a reimbursement of €1979.67 per patient at risk for malnutrition and a total reimbursement of €79,186.73 for all patients at risk for malnutrition in the present study. ConclusionEstablishment of a structured, comprehensive assessment of the nutritional status of hospitalized patients can repetitiously identify patients at risk for malnutrition. Additionally, the diligent codification of malnutrition can lead to cost compensation in the German Diagnosis-Related Group system.

Rolling Out the Capitation Payment System in Ghana: Lessons from the Pilot Implementation in Ashanti Region

This paper discusses the introduction of Capitation as a method of paying health care providers under Ghana's National Health Insurance Scheme. Currently, care providers under the scheme are reimbursed with fee-for-service payment system and Diagnosis Related Group system. In 2012, capitation was introduced on pilot basis in the Ashanti Region to help the scheme control cost and ensure financial sustainability of the scheme. The scheme is looking forward to nationwide rollout of the capitation system after a successful pilot implementation. The pilot program has, however, been bedeviled with some challenges that need to be resolved before the nationwide implementation. One major challenge is insufficiency of funds for health care providers who are paid under the capitation. There is therefore a high probability that health care providers would provide low quality services in order to cut down cost. We argue that the cost burden on health care providers can be attributed to two main factors. First, the capitation rate per person under the scheme is not risk-adjusted. Secondly, moral hazard behaviours on the part of clients have not been adequately dealt with. We recommend that these factors be adequately dealt with before the nationwide implementation.

Consideration of guidelines, recommendations and quality indicators for treatment of stroke in the dataset "Emergency Department" of DIVI

The dataset "Emergency Department" of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) has been developed during several expert meetings. Its goal is an all-encompassing documentation of the early clinical treatment of patients in emergency departments. Using the example of the index disease acute ischemic stroke (stroke), the aim was to analyze how far this approach has been fulfilled. In this study German, European and US American guidelines were used to analyze the extent of coverage of the datasets on current emergency department guidelines and recommendations from professional societies. In addition, it was examined whether the dataset includes recommended quality indicators (QI) for quality management (QM) and in a third step it was examined to what extent national provisions for billing are included. In each case a differentiation was made whether the respective rationale was primary, i.e. directly apparent or whether it was merely secondarily depicted by expertise. In the evaluation an additional differentiation was made between the level of recommendations and further quality relevant criteria. The modular design of the emergency department dataset comprising 676 data fields is briefly described. A total of 401 individual fields, divided into basic documentation, monitoring and specific neurological documentation of the treatment of stroke patients were considered. For 247 data fields a rationale was found. Partially overlapping, 78.9 % of 214 medical recommendations in 3 guidelines and 85.8 % of the 106 identified quality indicators were primarily covered. Of the 67 requirements for billing of performance of services, 55.5 % are primarily part of the emergency department dataset. Through appropriate expertise and documentation by a board certified neurologist, the results can be improved to almost 100 %. The index disease stroke illustrates that the emergency department dataset of the DIVI covers medical guidelines, especially 100 % of the German guidelines with a grade of recommendation. All necessary information to document the specialized stroke treatment procedure in the German diagnosis-related groups (DRG) system is also covered. The dataset is also suitable as a documentation tool of quality management, for example, to participate in the registry of the German Stroke Society (ADSR). Best results are obtained if the dataset is applied by a physician specialized in the treatment of patients with stroke (e.g. board certified neurologist). Finally the results show that changes in medical guidelines and recommendations for quality management as well as billing-relevant content should be implemented in the development of datasets for documentation to avoid duplicate documentation.

Performance evaluation of inpatients' medical service for major diseases in some Beijing municipal hospitals based on diagnosis-related groups

Objective To use diagnosis related group (DRGs) for the first time in overall evaluation of inpatient service performance evaluation of major diagnostic category (MDC) for all the Beijing municipal hospitals, and recommend how to strengthen Beijing municipal hospitals system in diagnosis and treatment ability of main diseases and improve inpateint service performance. Methods BJ-DRGs burster software was used to analyze the first page information of the medical records of cases discharged from all the Beijing municipal hospitals between 2012 and 2014 to determine the weight of each DRG, and based on such weight the related indicators of such hospitals and central hospitals in 2012, 2013, 2014 were compared and analyzed. Results Improvements were found in such indices as diagnosis and treatment difficulty of 50% MDC, time efficiency of 81.8% MDC, cost efficiency of 77.3% MDC, and general capacity of 54.5% MDC for all Beijing municipal hospitals. In addition, the municipal hospitals were found superior to the central hospitals in such indices as cost efficiency of 68.2% MDC, and time efficiency of 59.1% MDC. On the other hand however, they were found inferior to the central hospitals in such indices as diagnosis and treatment difficulty of 72.7% MDC, and the comprehensive ability index of the two systems were found equivalent. Another finding was that there was no obvious improvement of the coverage of disease types at major tertiary hospitals in Beijing for the past three years. Municipal hospitals of greater contribution of MDC weight were highly consistent with the hospitals assigned with national key projects of disciplinary developments. Conclusion The comprehensive evaluation results of inpatient service performance of main diseases at Beijing's municipal hospitals based on DRGs system, showed that the Beijing's hospital authority had played an important role in improving inpatient service performance especially in reducing the burden of patients, improving the service efficiency through increasing government investment, optimizing service organization and implementation of performance management. But it also suggested that measures such as collectivize construction and management should be taken to improve municipal hospitals' linical specialty ability, improve the MDC diagnosis and treatment difficulty, and resume their functions of tertiary hospitals. Key words: Diagnosis-related groups; Inpatients' medical service; Performance evaluation

Hospital financing in 2015. Relevant changes for rheumatology

The announced major reforms will most probably not have an impact on hospital financing before 2016. Nevertheless, the numerous minor changes in the legislative framework and the new version of the German diagnosis-related groups (G-DRG) system can be important for hospitals specialized in rheumatology. The following article presents the relevant changes and discusses the consequences for hospitals specialized in rheumatology.

Acute pain therapy in German hospitals as competitive factor. Do competition, ownership and case severity influence the practice of acute pain therapy?

Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management. A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin). For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI. In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

Effects of DRG-based hospital payment in Poland on treatment of patients with stroke

A prospective payment system based on Diagnosis Related Groups (DRGs) presents strong financial incentives to healthcare providers. These incentives may have intended as well as unintended consequences for the healthcare system. In this paper we use administrative data on stroke admissions to Polish hospitals in order to demonstrate the response of hospitals to the incentives embedded in the design of stroke-related groups in Poland. The design was intended to motivate hospitals for the development of specialized stroke units by paying significantly higher tariffs for treatment of patients in these units. As a result, an extensive network of stroke units has emerged. However, as it is shown in the paper, there is no evidence that outcomes in hospitals with stroke units are significantly different from outcomes in hospitals without stroke units. It is also demonstrated that the reliance on the length of stay as a major grouping variable provides incentives for regrouping patients into more expensive groups by extending their length of stay in stroke units. The results of the study are limited by the incompleteness of the casemix data. There is a need to develop information and audit systems which would further inform a revision of the DRG system aimed to reduce the risk of regrouping and up-coding.

Creating an identity for a heterogeneous system in health care

Purpose – This paper aims to discuss the implementation process for the new diagnosis-related groups (DRG) accounting system in the health-care sector, and the struggle to gain acceptance for the system. The emphasis is on the goals and the expected results of the system, and how the system finally becomes an actuality. Design/methodology/approach – The paper illustrates the framing of an accounting system, that is, how the health organization constructs the goals and the purposes of the system during its implementation. The empirical data consist of interviews, newspaper articles and notes from participatory observations. Findings – The goals and the purposes of the new system were not defined ex ante, but rather emerged as supporters of the system found a common language. This commonality enabled the linking of the interests of the hospital managers with the DRG system. At this point, the actual DRG-based systems for the product categorization and the full-cost pricing system became heterogeneous. Making the system visible through discussion entailed seeing the invisible. Seeing the invisible allowed the system to become a reality (national comparability). Visibility helped the DRG system to gain approval and become a stronger system. Research limitations/implications – This study is an illustration of a unique social process. The study’s applicability under other circumstances should be considered with caution. Originality/value – The paper illustrates how the purpose of an accounting system emerges and is constructed through the interaction between various actors.

French Multicenter Evaluation of the Appropriateness of Admission to the Emergency Department of the Over-80s.

Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays. The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance. During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions. Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life.

Study about Economic Adequacy of Tonsillectomy and Adenoidectomy Based on Medical Prime Costs

Received April 20, 2015 Revised May 28, 2015 Accepted May 29, 2015 Address for correspondence Jung Hyun Chang, MD, PhD Department of OtolaryngologyHead and Neck Surgery, National Health Insurance Corporation Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea Tel +82-31-900-0346 Fax +82-31-900-0972 E-mail manbang5@naver.com Background and ObjectivesZZThe Korean National Health Insurance is based on ‘fee for service’ system, but recently 7 groups of diseases were forcibly applied to diagnosis related groups (DRG) system. In these 7 group of diseases, tonsillectomy and adenoidectomy were included in the otorhinolaryngology field. The objective of this research is to estimate the invested medical costs, profit and loss, and improvement points for the disease groups according to DRG and ‘fee for service’ system. Subjects and MethodZZWe investigated 1,377 subjects who underwent tonsillectomy and adenoidectomy based on DRG between January 2011 to December 2013 at our hospital. The profit and loss of medical costs were calculated according to medical record data, medical service fee, and activity based costing (ABC). ResultsZZThe total of 1,377 subject comprised of 905 patients younger than 17 years-old and 472 patients older than 18 years-old. A main moderate complication that was not one of the DRG diseases, postoperative bleeding, was only found in 19 patients (1.38%). Profit related to tonsillectomy and adenoidectomy studied for a 3 year-period was higher in the DRG system than in the ‘fee for service’ system; however, profit was reported as 62.9-67.5% of the actual prime costs. ConclusionZZDRG system for tonsillectomy and adenoidectomy seems to have higher compensation rate than the ‘fee for service’ system does. However, the system is still insufficient to compare profit with the input medical cost. Furthermore, the present system of disease grouping needs to be improved to reflect actual medical prime costs. Korean J Otorhinolaryngol-Head Neck Surg 2015;58(9):628-33