Diagnostic Related Groups Research Articles

Hospital cost, cancer patients, and gynecology diagnostic related groups

Hospital cost, cancer patients, and gynecology diagnostic related groups

Maximizing the Functional Status of Geriatric Patients in an Acute Community Hospital Setting

Patients (n = 103) admitted to an inpatient geriatric care unit focusing on restoration of functional status were compared to similar patients (n = 75) admitted to a control-unit. Study unit patients showed significantly greater improvement in basic functional capabilities from admission to discharge than did control-unit patients. A mixed picture evolved when length of stay and total charges of study and control-unit patient were compared by diagnostic-related groups.

Advances in rapid preliminary and definitive identification of anaerobes

In this era of diagnostic-related groups and emphasis on cost-effective laboratory services, the question of how far to go with the identification of anaerobic bacteria in the clinical laboratory assumes added significance. In principle, there are three main reasons to identify anaerobes from clinical specimens: 1) epidemiological (e.g., isolation of Bacteroides bivius/disiens from female genital tract specimens or association of Clostridium septicum with malignancy), 2) delineation of an organism or organism group's role in specific disease processes, or 3) differentiation in antimicrobial susceptibility between different species and groups.

Hospital costs, cancer patients, and surgical diagnostic related groups

This study of 4,359 Medicare patients in 107 noncancer stratified surgical Diagnostic Related Groups (DRGs) tested the hypothesis that patients with a diagnosis of a malignancy (i.e., cancer) in these DRGs would have higher resource utilization than patients without a diagnosis of a malignancy (i.e., noncancer) in these same surgical DRGs. The 1,008 cancer patients had 3.2 times the financial loss ($1,617 per patient vs. $510 per patient) compared to the 3,351 noncancer patients (P less than .05). Patients with cancer had a greater percentage of outliers, more diagnosis (P less than .0001) and procedures (P less than .0001) per patient, and a higher mortality (P less than .01) than patients without cancer. These findings raise the question of the equity of DRG payment for patients with cancer in many surgical DRGs. Financial disincentives to treat certain groups of Medicare cancer patients at our hospital may affect both their access and quality of care in the future.

Hospital costs, cancer patients, and gynecology diagnostic related groups

This study of 115 Medicare gynecology patients in five noncancer-designated gynecology diagnostic related groups (DRGs) demonstrated that patients with a diagnosis of a malignancy ( N = 52) had significantly higher hospital resource utilization compared to patients without a malignancy ( N = 63) in these gynecology DRGs. Cancer patients had higher total hospital costs ( P < 0.001), longer hospital length of stay ( P < 0.01), significant financial losses under DRGs ( P < 0.01), greater percentage of outliers ( P < 0.05), greater severity of illness, and greater mortality ( P < 0.001) compared to noncancer patients in these same gynecology DRGs. These findings raise the question of whether hospitals will be adequately reimbursed by DRGs for many gynecology cancer patients. Disincentives for hospitals to treat gynecology cancer patients under the current DRG reimbursement system may affect both the access to and the quality of care.

Hospital costs and resource characteristics for cardiothoracic surgical hospital deaths

No major changes in the federal Medicare diagnosticrelated group (DRG) prospective hospital payment system have been implemented by the United States Congress. We analyzed hospital resource consumption for 1,567 cardiothoracic surgical patients by outcome (ie, survivors versus nonsurvivors). The 76 patients who died had a much greater intensity of hospital resource utilization and represented a substantial financial risk under DRG pricing schemes compared with the 1,491 survivors. Only patients who died within 1 week of admission to the hospital generated a financial surplus under DRGs. A long hospital stay for nonsurvivors produced a substantial deficit (patients with a stay greater than 60 days generated a $154,433 loss per patient). The cardiothoracic patients admitted on an emergency basis who died tended to have a shorter length of stay and represented a lower financial risk under DRGs compared with patients admitted on a nonemergency basis who died. Among nonsurvivors, patients referred for cardiothoracic surgical procedures from other clinical services had lower resource utilization and financial risk ander DRGs compared with nonreferrals. These data suggest significant inequities in the current DRG prospective payment system vis-à-vis cardiothoracic surgical patients who die. Variables predictive of greater hospital resource utilization by outcome included a longer hospital stay, nonemergency admission, and admission directly to the cardiothoracic surgical service. Methods to improve the equity of DRG payment vis-à-vis cardiothoracic surgical nonsurvivors should be implemented in the future.

Financial risk and hospital cost for elderly patients in non-age stratified urology DRGS

The Diagnostic Related Group (DRG) hospital payment system may be inequitable for certain groups of Medicare patients. This study of 216 Medicare urology patients in the ten nonage stratified urology DRGS demonstrated that patients seventy years of age and older (70+) had higher resource consumption than patients under seventy years of age (70 − ). Findings were: (1) older patients (70 + ) had higher total hospital costs ($12,022 per patient) than younger patients (70 − ) ($9,872 per patient); (2) a longer hospital length of stay (14.2 days vs 11.6 days); (3) financial risk of $1, 756 loss per (70 + ) patient vs $1,309 profit per (70 − ) patient (p < 0.05); (4) more diagnoses and procedures per patient, and (5) a higher mortality (4.0 % vs 3.3 %). These findings suggest that the current DRG scheme may be inequitable vis-a-vis the older urology patient in nonage stratified DR Gs, and thus could limit access and quality of care for these patients in the future.

Continuous mechanical turning of intensive care unit patients shortens length of stay in some diagnostic-related groups

Periodic changing of body position is a commonly used, generally accepted modality of intensive care unit (ICU) patient care, but the optimum frequency for turning has not been established. In order to evaluate the effect of continuous turning, 86 patients were randomized to either continuous turning on a Kinetic Treatment Table (KTT) or routine turning on conventional beds every two hours by the nursing staff. Although overall ICU mortality, length of stay, APACHE-II score, duration of mechanical ventilatory management, and incidence of nosocomial pneumonia were similar in the two groups, significant differences occurred in certain subsets of patients: continously turned patients with sepsis and pneumonia had a 3.48-day shorter adjusted length of ICU stay compared with controls ( P < .001). Chronic obstructive pulmonary disease patients on the KTT also required 6.84 fewer days ( P < .001) in the ICU and 4.6 days less of mechanical ventilation ( P < .001) than controls and had a lower final APACHE-II score. These data suggest that continuous turning on a mechanical platform shortens the requirements for length of stay and assisted ventilation in certain critically ill patients, thereby providing a major reduction in the financial costs of medical care.

Meeting Diagnostic Related Group Goals for Elderly Patients

Strong economic incentives for prompt discharge under the diagnostic related group (DRG) system challenge hospital social workers to balance the needs of individual patients and the needs of their employing institution. A sample of 219 elderly patients at a large, urban teaching hospital were assigned to regular or early intervention groups. The relationships among timing, type, and amount of social work intervention; ability of patients to care for themselves; availability of social support; and other variables were examined. Early and adequate social work diagnosis and intervention tended to limit excessive hospital stays and facilitate the institution's ability to adhere to DRG guidelines.

Impact of Medicare Prospective Reimbursement System on Nutritional Support Service Patients: The Importance of Pass Throughs

The financial data of all patients (535) admitted to the Nutritional Support Service (NSS) during 1985, including charges, true care costs, and actual reimbursement including pass-through payments (which are Medicare funds given directly to hospitals for education and capital equipment, and vary significantly from hospital to hospital), were analyzed. The NSS Medicare patients fell into 98 diagnostic related groups (DRGs). All 3,939 Medicare patients admitted in 1985 with the same DRGs as the NSS patients were also identified and their financial data analyzed. The NSS patients lost $999,643 because of the 266 medicare reimbursed NSS patients sustained high losses which overwhelmed the modest profits of the 269 non-Medicare patients. When data from all Medicare patients (which includes both NSS and non-NSS patients) with the same DRGs are analyzed, large profits are realized. These profits are totally due to pass-through payments received. Without pass throughs the loss for all 3,939 Medicare patients in these 98 DRGs would have been $1,641,273. The impact of eliminating pass throughs in the next few years needs to be determined. NSS patients represent a group that generates high financial losses under the federal prospective reimbursement system. However, present Medicare reimbursement of other less seriously ill patients with similar DRGs more than compensate these losses if pass throughs are used in determining reimbursements.

Differences in the approaches of the doctor, manager, politician and social scientist in health care controversies—Hospital case-mix management methods: An illustration of the manager's approach in health care controversies

Resource allocation methods in health care are one of the major sources of controversies between managers, doctors, politicians and social scientists. In the past 10 years, an important innovation has appeared in hospital management and payment methods: case based systems, the most well known being the Diagnostic Related Group (DRG), that have been used for 5 years by Medicare in the U.S.A. to pay for hospital care. Through the analysis of the diffusion of DRGs in the U.S.A. and in France, we support the idea that DRGs are a typical illustration of the managerial approach to health care. They represent a significant breach in professional autonomy through the introduction of bureaucratic rationality. We also show how scientific controversies are structured by the dynamics of the diffusion of case based management systems.

Cost-related Variables

The advent of prospective payment systems prompts nurses to examine cost-related factors in demonstrating savings resulting from quality care. The clinical nurse specialist plays an active role in the examination of variables influencing costs for patients within the specialty. This pilot study utilized a retrospective chart audit of 142 women falling within Diagnostic-related Group 355 (non-radical hysterectomy, age less than 70 years, without comorbid condition or complication) during 1985 to identify demographic, illness/treatment-related, and discharge variables related to charge variance. Independent (length of stay, p less than 0.001 and previous admission, p = 0.066) predictors of charge variance were found among the 14 variables studied. The value of the research as a model for other practitioners is discussed.

DRGs, orthopedic surgery, and age at an academic medical center.

The federal Medicare Diagnostic Related Group (DRG) hospital reimbursement system has been on line for 5 years. Hospitals contend that profit margins have dropped to dangerously low levels, due to the federal DRG Prospective Payment System. The authors analyzed all orthopedic surgical admissions to a large academic medical center under DRG reimbursement and characterized patients by age, resource utilization, and outcome. Total costs for the 1,040 orthopedic patients analyzed during a 15-month period added up to $9,718,800. Mean hospital cost per patient, mean hospital length of stay, percent outliers, and mortality generally increased with age. All age categories of patients 65 years of age and above generated financial losses under DRGs. Older orthopedic patients consumed a disproportionately larger share of resources than younger patients, and were more frequent users of the SICU and blood. The current DRG reimbursement scheme may be inequitable in relation to the older orthopedic surgery patient. If these findings are demonstrated at other medical centers, older orthopedic surgical patients could be limited in both their access and quality of care in the future.

Physicians and DRGs. Hospital management alternatives.

Rising health care costs in general and hospital costs in particular have placed significant financial strain on federal programs such as Medicare. It was with this in mind that the Reagan administration in 1983 initiated Medicare's new prospective payment system based on diagnostic-related groups (DRGs) to reduce the growth rate of Medicare expenditures. The introduction of DRGs has generated significant controversy in the health care community. The DRG system may necessitate consideration of four new management alternatives by hospital administrators: increased monitoring and regulation of physicians, profit-loss sharing arrangements between physicians and hospital management, development of collective protocols among physicians, and bedside budget balancing. This study examines the opinions of a random sample of 838 physicians from the West North-Central region regarding these management alternatives. The findings suggest that physicians have strong negative opinions about these management alternatives and believe that they will have a negative impact on the health care system. The development of collective protocols emerges as the most likely acceptable alternative among physicians, but even collective protocols as an alternative promise limited success.

Financial risk, hospital cost, complications and comorbidities (CCc) in non-CC stratified urology diagnostic related groups

The federal Medicare Diagnosis Related Group payment mechanism is undergoing constant change. Significant interest has been generated at the health policy level regarding reimbursement for patients with complications and comorbidities. The purpose of this study was to analyze hospital resource consumption for patients in the seventeen urology non-complicating condition (CC) stratified Diagnostic Related Groups (DRGs), currently 45 percent of urology DRGs. We analyzed 185 Medicare patients in these non-CC stratified urology DRGs and found that patients with more CCs per patient had higher total hospital costs per patient, financial risk under DRGs, a greater percentage of outliers, and a higher mortality, than patients in these same DRGs with fewer CCs per patient. These findings suggest that the current DRG system is inequitable to some patients and certain hospitals vis-a-vis non-CC stratified urology DRGs. The Health Care Financing Administration has not significantly changed the complicating condition urology DRG classification, as of its recent May, 1988 legislation. Financial disincentives to treat these patients may affect both their access and quality of care in the future.

The private practice of infectious diseases--a current assessment.

private practice comprise established areas of expertise? What elements are more recent additions to the legitimate repertoire of the infectious diseases specialist? What lies ahead for our rapidly expanding subspecialty? The core of any specialty practice is hospital consultation. In an era of procedures, the infectious diseases physician stands alone in providing more traditional consultative services. The keys to success have always been prompt availability, realistic patient care recommendations, and communication with the referring physician. The advent of diagnostic-related groups (DRGs) and fixed payment care ensures that the severity of illness index of hospitalized patients is increasing. The final common pathway for many complex illnesses is nosocomial infection. Furthermore, aggressive use of toxic antineoplastic regimens and the expanded use of allograft organ transplantation results in recipient immunosuppression with heightened risk for opportunistic infection. Thus, the patient base requiring our expertise is expanding rather than contracting. The management of highrisk patients lends itself to a multidisciplinary approach

The identifier concept: Variables to stratify patient costs within cardiothoracic surgical diagnostic related groups

Prospective payment systems using the diagnostic related group payment mechanism are changing the economic incentives offered to hospitals. This study of all cardiothoracic surgical patients (N = 1825) treated during a 2-year period at an academic medical center demonstrated that patients within cardiothoracic diagnostic related groups could be stratified as to resource consumption (i.e., hospital cost) by four clinical variables: intensive care unit or emergency admission and blood and plasma product utilization. Patients within each diagnostic related group with the variable had higher hospital costs as follows: intensive care unit (100% of patients had higher costs per diagnostic related group for intensive care unit versus non-intensive care unit admissions), blood (100% of patients), plasma product (100%), and emergency admission (92.2%). In addition, hospital costs increased as the factors accumulated. This study demonstrates that costs within cardiothoracic diagnostic related groups may be grouped by four clinical parameters that occur during the patient's hospital stay. One of these variables (i.e., emergency admission) may be suitable to modify diagnostic related group payment. The other variables could segment higher cost patients within a diagnostic related group; cost containment efforts directed at these patients might then provide savings for the hospital.

Surgonomics: the costs of ruptured abdominal aortic aneurysm.

Surgical care costs continue to rise at a rate greater than overall U.S. economic growth. Government and industry have vowed to slow the growth of health care spending. Prospective payment systems using the Diagnostic Related Group (DRG) mechanism are being phased in for payment of in-patient hospital care. One expected effect of the DRG payment scheme is a more careful financial analysis of the components of surgical care. The purposes of this study were to examine a vascular procedure, ruptured abdominal aortic aneurysm (RAAA), performed at a large teaching hospital during a ten-year period; to characterize patients by cost (hospital charges exclusive of physician fees) and outcome; and to test the hypothesis that an IDENTIFIER, here the presence or absence and duration of hypotension (less than 90 mm Hg systolic), could predict differences in cost and outcome. The results, in conjunction with historic data, were used to quantify aggregate hospital expenditures for this condition by survivor and the identifier. The results indicate: (1) mortality is higher for the hypotensive patient than for the normotensive patient (p less than 0.05) and is related to the duration of hypotension; (2) lowest mean charges per patient were in the hypotensive more than thirty minutes group ($5,587) followed by normotensive ($28,298), then hypotensive less than thirty minutes ($43,876); and (3) the mean charges for each survivor were $42,447 for normotensive patients versus $107,572 for hypotensive patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Resource Utilization Groups: DRGs Move to Long-Term Care

The costs associated with a growing population of elderly persons in the United States combined with a need to restrain escalating acute care costs led to the development of a prospective payment system (PPS) for institutional long-term care in New York State. Although similar types of PPS exist in several other states, it is expected that RUGs will become the model for the nation. The price paid is based on a formula that combines the direct care components of care with allocated medical and ancillary costs per patient. Based on a patient classification case-mix system, the Resource Utilization Group (RUG) relies on specific nursing documentation of patient care delivered, that is, resource used. Implemented at the same time as diagnostic-related groups (DRGs), the RUGs system is not based on length of stay, diagnosis, or age. Activities of daily living (ADL) drive the system and, in that sense, RUGs has some similarities to severity of illness models. There are 16 RUGs (that is, 16 case-mix indexes and 16 prices), ranging from skilled rehabilitation and intensive skilled nursing care to light custodial care. Patients assessed at the low end of the spectrum — light care, lowest price — may be denied admission to nursing homes as well as prepared for discharge to the community or a lighter level of care. Discharge planning and patient teaching for less dependent living are recent phenomena in nursing homes. Nurses have to learn how to manage the complex, technologically dependent patient as well as learn aspects of preparing the patient — and family — for discharge. The challenge to nursing is to protect the patient from negative incentives inherent in the RUGs system; analyze the nursing process and productivity; and contribute to research that should be observing the effect of the reimbursement system on the quality of care.

Impact of the diagnostic-related group prospective payment system on the outcome and quality of care of elderly patients hospitalized with pneumonia.

In order to determine whether the institution of the Medicare prospective payment system has led to poorer outcome and quality of care for patients hos pitalized with pneumonia at the Hershey Medical Center, a critical review of elderly pneumonia pa tients was performed for two time periods. The first time period was July 1981 through June 1982 (pre- diagnostic-related group era). The second time period was July 1984 through June 1985 (diagnostic-re lated group era). There were no significant differ ences between these two groups in terms of age, se verity of illness, and mean length of stay. The number of deaths was virtually identical for each group (ap proximately 27% mortality overall). We were unable to show any differences in the quality of care by a structured process of care review. Thus, we conclude that the prospective payment system has not had a negative impact on outcome or quality of patient care in patients hospitalized with pneumonia at this uni versity hospital.