Diagnostic Related Groups Research Articles

Swedish physicians' perspectives on the introduction of the Stockholm model.

Reports findings on the perspectives of Swedish physicians since the introduction of the Stockholm model. Subjects were asked to describe their work, how long they had been working and whether they were familiar with the Stockholm model. Questions also focused on professional autonomy, use of diagnostic related groups (DRGs), quality of care and competition among health-care providers. Most of the physicians interviewed reported that the Stockholm model had the advantage of increasing efficiency and productivity, that economic incentives influenced their medical decisions, and medical treatment appears more patient-focused than before. Finally, primary care physicians report an enhanced status within the medical profession.

Predicting length of stay in psychiatry.

Diagnostic Related Groups (DRGs) and Healthcare Resource Groups (HRGs) do not predict accurately length of stay or resources needed for treatment in psychiatry. This preliminary study assessed the relative contribution of severity of illness, in combination with other variables, in predicting length of stay. Data were analysed on 115 consecutive admissions to a district psychiatric in-patient unit to assess the variables which most accurately predict length of stay. The variables included demographic data, diagnosis, clinical, social and behavioural measures. For initial admission, diagnosis of neurosis predicted shortest stay, but diagnosis alone accounted for only 14.6% of the variation in length of stay. Addition of Social Behaviour Scale score, living alone and specific psychiatric symptoms significantly increased the predictive value (adjusted R2 = 36.6%). Addition of variables available at discharge (use of ECT, major tranquillizers and antidepressants) significantly increased the adjusted R2 to 49.0%. Prediction of total length of hospitalization over a 12-month period, from the date of initial admission, indicated that mania predicted the longest stay and addition of other variables meant that only 18.9% of length of stay was predicted. If these results are borne out in a large study, they indicate that diagnostic or health related groups (DRGs) are only likely to be useful in psychiatry if they include more detailed social, clinical and behavioural variables.

Hospitalization for Skin Disease Improves Quality of Life

Inpatient dermatologic services are diminishing. A recent survey¹of dermatology residents reports that 17% do not care for hospitalized patients and that less than 1% of residents care for 60 or more hospitalized patients per month. One reason for this decrease is the increasing pressure to contain medical costs. Stringent guidelines have been set up for hospital admission, length of stay, and intensity of care, all encompassed in a specific diagnostic related group that represents a certain sum for a given diagnosis. Despite these firm criteria, few objective tests are used routinely to assess the outcome, effectiveness, or cost of dermatologic hospitalization. One outcome measure is the Psoriasis Area and Severity Index, which is often used to quantify the effectiveness of treatments for psoriasis.²In addition, a patient-oriented measure of outcome, the Dermatology Life Quality Index, and other depression and anxiety tests can be used to measure objectively

Clinical pathways for the high-risk patient

The goal of managed health care is to reduce health care costs while maintaining or improving the quality of care given to patients. Clinical pathways, which outline the services and therapies planned for a typical patient admitted with a specific diagnosis, may provide a way to control costs and improve patient outcome. These pathways are under development by medical centers and managed-care organizations nationwide, with the aim of planning, managing, documenting, and evaluating multidisciplinary care. A coordinated care plan can take a number of approaches. Time lines identify predictable clinical landmarks and time intervals for a specific medical episode or illness within a given diagnostic-related group or set of diagnostic-related groups. Case-management plans and case managers coordinate a patient's care throughout an episode, eg, an operation, enabling patients to reach defined time points in the course of their care at the expected time. Critical pathways are the favored method of documenting the patient's progress according to the predicted time schedule. This report discusses ways to successfully implement a care plan, highlighting the commitment and effort needed from a multidisciplinary staff to achieve the goal of optimizing efficiency and quality of patient care.

Practitioner or provider: Are they mutually exclusive?

Practitioner or provider: Are they mutually exclusive?

Basic Treatment Equivalent (BTE): A new measure of linear accelerator workload

The measurement of linear accelerator workload in radiation oncology departments is usually based on the number of fields treated per unit time. However, this approach ignores variations in treatment complexity. This prospective study, was designed to measure treatment workload directly, taking into account the variations in complexity of different treatment techniques. From this, a model was to be developed, which would be simple to apply and reproducible, both within and between radiation oncology departments in Australasia. It would provide a realistic basis for assessing treatment costs and enable the comparison of patient throughput between departments. This paper describes the derivation of the model. Over a 4-week period in the Radiation Oncology Department of Westmead Hospital, all fractions of radiotherapy were timed. The data collected included: tumour site; treatment intent; number of fields; number of wedges, compensators and shielding blocks; fraction number; patient age; performance status; and need for general anaesthesia. Multivariate modelling was performed to identify factors that significantly affected fraction duration, so that these could be used to develop a model of resource utilization. The durations of 2371 fractions were measured in 219 patients. Seventy-five per cent of fractions were given with radical intent. The factors found to influence fraction duration on multivariate modelling were: number of fields; number of shielding blocks; first treatment fraction; need for anaesthesia; and performance status. The number of wedges and compensators were also found to be significant but were not included in the model in order to maintain simplicity. This was felt to be necessary if the model is to be applied to the widest possible variety of machines. A model of resources utilization called ‘Basic Treatment Equivalent’ (BTE) was derived, which incorporated these factors. When tested at Westmead Hospital, this model accurately reflected the predicted BTE value over a further 1-week study period. This model of linear accelerator use, which incorporates complexity has been derived and evaluated in one radiation oncology department. This requires further prospective testing before its widespread use. The model appears to reflect linear accelerator workload better than previous measures. An Australasian study to validate the model further will be undertaken. If adopted, this model has implications for comparative workload reports, diagnostic-related groups, waiting list calculations, and patient scheduling.

Costing the diagnostic related group of diseases (DRGs): A case study of Chulalongkorn Hospital

Costing the diagnostic related group of diseases (DRGs): A case study of Chulalongkorn Hospital

Clinical care pathways in a surgical epilepsy program: A comparison of costs by diagnostic related groups for program and nonprogram admissions

Specific diagnostic related groups (DRGs) for patients investigated and treated in a surgical epilepsy program have not been established. This has raised concern that admissions into such a program are categorized into DRGs that do not accurately reflect resource consumption. Three DRGs commonly pertain to surgical epilepsy program admissions: 001, 024, and 025. We established clinical care pathways to allow for the diversity of clinical presentations and the differences in subsequent investigation with or without surgical treatment and categorized financial data for 50 patients completing the surgical epilepsy program from June 1993 through December 1994 for the purposes of comparing costs among clinical pathways along with that for 1,401 patients who were not in the program but who were discharged under the same DRGs during the same period. Four clinical pathways contained sufficient patient volume to allow comparison among the pathways and with nonprogram-related admissions under the same DRGs. A considerable range of cost ($1,576–$86,653) was identified among the four most common clinical care pathways. The two pathways involving intracranial electrode implantation followed by prolonged electrographic monitoring were distinguished by the necessity for a subsequent surgical admission as opposed to resection of the epileptogenic area at the time of electrode removal. The cost incurred by an additional admission increased by 14% to $64,305. The mean cost of program patients discharged under each DRG was significantly higher than that for other patients: DRG 001, $28,439 versus $22,289, p p p

Effect of Early Nutrition Intervention on Patient Length of Stay

LEARNING OUTCOME: To demonstrate the effectiveness of early nutrition intervention on LOS in elderly patients at risk for malnutrition.A multisite study facilities in Colorado provided the data for this summative analysis of the relationship between length of stay (LOS) and nutritional status in Medicare patients (aged ≥ 65) from 3 diagnostic related groups (DRGs). The purpose of the study was to determine if early (within 48 hours of admission), delayed (≥ 72-96 hours) or no nutrition intervention influenced LOS for patients assessed at two levels of nutritional risk: 1) potential risk (PR), or 2) risk (R). A total of 514 patients with DRG admission codes 89 (pneumonia), 127 (heart failure/shock) and 148 (all bowel procedures) were included in the study if they were assessed within 48 hrs of hospital admission and had LOS between 4 and 40 days. Patients were identified at PR if one of the following criteria was present: albumin > 2.5g/dl but < 3.5, % IBW = 80-90, TPN ≥ 1 day, TF. ≥ 1 day. R criteria included one or more of the following: albumin < 2.5 g/dl, % IBW < 80, TPN or TF plus % IBW = 80-90, TPN or TF plus albumin > 2.5g/dl but < 3.4, albumin > 2.5g/dl but < 3.4 plus % IBW = 80-90. Nutrition intervention consisted primarily of oral supplements and snacks, but also included TF and TPN. 34% of patients were identified at PR and 21% were identified at R. Mean LOS for R patients in early intervention group (n=41) was 9.1 d; this was significantly shorter (p<.05) than R patients receiving delayed (n=28, 123d) and 12.2d with no nutrition intervention (n=20). For the PR group, mean LOS , 9.1 d for patients receiving early nutrition intervention (n=57),9.9 d for delayed (n=30) and 8.7 d for no nutrition intervention (n=54) were not significantly different. Mean LOS was significantly shorter (p <0.05) for adequately nourished patients (6.4 d) compared to all PR (9.5 d) and all R (10.2 d). These data show that more than half of the Medicare population studied was at PR or R for malnutrition. More importantly, the results suggest early nutrition intervention has an impact on LOS for patients identified at nutrition risk and therefore, may provide future hospital cost savings.

Case Mix Index

Many authors curse diagnostic-related groups (DRGs) and project a dismal financial picture. Optimization places the health care professional in the driver's seat. It allows maximum financial benefit for the actual care provided, enhances the reimbursement to the facility and provides every nurse a method to gain credit for what they do on a daily basis.

Planning home care services: which data do we need?

In Italy, as is true throughout the developed world, care in the home is becoming central to the delivery of almost all health care services to much of the population, especially those who are elderly. Although there are many reasons why this is true, including the dramatic changes in the demographic characteristics of the population being served, financial considerations are surely the proximate and most visible cause. As Diagnostic Related Groupings (DRG) are introduced with a fixed payment for acute institutional care for a given condition, regardless of the duration of stay, hospitals will increasingly have an incentive to shorten the period of hospital care. This will necessitate the provision of much care, previously provided on an in-hospital basis, to be delivered in the home setting. These changes in the site of care will demand considerations about the education of all types of professionals but especially physicians who traditionally have had little direct involvement in care in the home. In addition, there will be a requirement for an expansion in health care research so that comparisons of services and sites can be carried out with an eye to determining the most cost-effective way to provide for care. Lastly, epidemiologic studies will be needed to address the risk factors of those chronic diseases so frequently a cause of functional impairment requiring home care services.

The Effects of Case Management on Clinical Nutrition Practice for the Coronary Artery Bypass Graft Surgery Patient

Case Management is a systemic clinical process which provides quality patient care within a predetermined time frame established by dianostic related groups. To achieve our goals, critical care paths were developed for selected diagnostic related groups. The pilot diagnostic related group for case management was the coronary artery bypass graft, which is a high volume case type. Collaboration with an interdisciplinary team, including the registered dietitian was the primary focus of this practice model. The greatest challenge for the dietitian was to educate more high acuity level patients within a shortened length of stay. In order to accomplish this goal, the following changes were made: a general assessment replaced an in-depth assessment of nutritional needs, weekly classes were changed from two, thirty minute classes to three fifteen minute classes, class content and informational materials were condensed, self-select hospital television educational programs were made available for patient viewing, and scheduled programming was discontinued. Finally, referral for follow-up was made to the newly created outpatient nutrition services. We believed this setting would be more appropriate to meet the long-term nutrition education needs of the patient. As a result of the case management changes contributed by all disciplines, a five day reduction in length of hospital stay and a savings of $1.5 million to the hospital was realized. Case management has now been applied to other cardiovascular diagnostic related groups as well as orthopedics, endocrinology, neurology, psychiatry, and respiratory. In all of these areas, the clinical dietitian is responsible for providing specialized nutrition therapies to patient and family populations and increasing patient satisfaction, while being accountable to fellow providers as a key member of a successful case management team.

Factors Predicting Early Non-Elective Hospital Readmission of Nutritionally Compromised Older Adults

With the implementation of Diagnostic Related Groups (DRGs) as the basis of hospital reimbursement, the average length of hospital stay has declined. As a result, elderly patients are being discharged from short-stay hospitals more rapidly than those with similar illnesses in the past. This may result in more frequent need for early non-elective readmission. Predicting which elderly persons may be readmitted will enable preventative interventions to reduce overall health care costs. The purpose of this study was to determine predictors and assess predictive models of early non-elective hospital readmission. The sample consists of 134 male and female Medicare patients who were found to be nutritionally compromised at the time of discharge. The study is a secondary data analysis utilizing a repeated measures design of multiple variables representing demographics, anthropometries, laboratory values, and impairment in Activities of Daily Living (ADLs). Data have been collected at four time points: at hospital discharge, and during dietitian or nurse home visits at one week, one month, and three months post discharge. Bivariate logistic regression analysis reveal that serum albumin and change in weight measured at one month post discharge are highly significant predictors of readmission. There is a 31% decrease in the log odds of readmission associated with every 0.1 unit increase in serum albumin at one month post discharge (Wald χ2 = 8.2748, p = 0.0040), such that an albumin value of 3.3mg/dL relates to a 51% probability of early non-elective readmission compared to an albumin value of 3.7mg/dL with a 20% probability of readmission. Serum albumin at one month post discharge accounts for approximately 28% of the variance in non-elective readmission (McFadden's R2 = .2753). For every kilogram of weight loss, there is a 75% increase in the odds of readmission (Wald χ2 = 5.1757, p = 0.0229). Change in weight accounts for 8% of the variability in non-elective readmission (McFadden's R2 = .0843). It is of interest that serum albumin measured at the time of hospital discharge was not significantly associated with non-elective readmission in this population. This suggests that an evaluation of serum albumin and change in body weight should be routine during early post-hospitalization office visits to identify those at increased risk of early non-elective readmission.

Centrifugal Pumping: The Patient Outcome Benefits Following Coronary Artery Bypass Surgery

The increased use of the centrifugal pump during coronary artery bypass surgery has been based primarily on theoretical data related to patient safety. There is minimal evidence suggesting improved outcome when compared to the traditional roller pump technology. We prospectively randomized 200 patients undergoing elective coronary artery bypass grafting into centrifugal pump (100 patients) and roller pump (100 patients) groups to compare differences in blood product usage, complication rate, length of stay and net hospital financial balance. Moderate hypothermic bypass was employed on all patients. Cardiopulmonary bypass circuits were similar in both groups with the exception of the arterial pump. Both groups were statistically identical in regard to age, sex, surgeon, complications, total pump time, aortic cross clamp time, prebypass hematocrit and platelet count. The twenty-four hour postoperative hematocrits, platelet counts, red blood cell requirements, blood loss and mortality (2%) were identical in both groups. The centrifugal pump patients had less 24 hour weight gain than their peers in the roller pump group (p=0.05) The length of stay and net hospital financial balance were also statistically favored in the centrifugal pump group (p&lt;0.05). These latter findings were significant when studied in all payors and coronary artery bypass diagnostic related group classifications. Although the mechanism for improvement in length of stay and net hospital financial balance cannot fully be explained, the ramifications in an increasingly cost conscious environment are obvious.

Operationalizing a bedside pen entry notebook clinical database system in consultation-liaison psychiatry

No current system of computerized data entry of clinical information in consultation-liaison (C-L) psychiatry has been well received or has demonstrated that it saves the consultant's time. The inability to achieve accurate, complete, systematic collection of discrete variables and data entry in the harried C-L setting is a major impediment to the advancement of the subspecialty and health services research. The hand-held Notebook computer with Windows PEN ENTRY MICROCARES capabilities has permitted one-time direct entry of data at the time of collection at the patient's bedside. Variable choice and selection enhances the completeness and accuracy of data collection. For example, ICD-9, Axis III diagnoses may be selected from a “look-up” which at the same time automatically assigns the appropriate code and diagnostic-related groups (DRG) number. A patient narrative can be typed at the nurse's station, a chart note printed for the medical record, and the MICRO-CARES literature database perused with the printing of selected citations, abstracts, and in some cases experts' commentaries for the consultee. The consultant's documentation time is halved using the NOTEBOOK WINDOWS PEN ENTRY MICRO-CARES software, with the advantage of more accurate and complete data description than with the traditional handwritten consultation records. Consultees preferred typewritten in contrast to handwritten notes. The cost of the hardware (about $2000) is less than that of an optical scanner, and it permits report generation and archival searches at the nurses' station without returning to the C-L office for scanning. Radio frequency or ethernet download from the Notebook permits direct data transfer to th C-L office archive computer.

Development of a self-care guide for postpartum fatigue

I~ ATIGUE is one of the most common complaints of newly delivered mothers (Affonso, 1987; Campbell, 1986; Evans, 1991; Gardner & Campbell, 1991). The condition has been defined as overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work (Piper, 1989, p. 189). In fact, fatigue was found to be the major concern for multiparas and the second most pressing concern for primiparas at 31/2 weeks after delivery (Smith, 1989). Fatigue affects the postpartum woman's quality of life, and it can affect her family. Fatigue can interfere with the mother's health and well-being (Mead-Bennett, 1990) and with the development of the mother-infant relationship (Gardner & Campbell, 1991). In recent years, the problem of fatigue potentially has been increased by the shortening of postpartum hospital stays. Before diagnostic-related groups were introduced, the average length of hospitalization after vaginal delivery was 3 days (Holmes & Magiera, 1987); now the stay may be as brief as 12 hours. Consequently, the mother has less time for in-hospital rest, away from her usual household duties, and fewer opportunities for assistance in learning to care for the newborn and for herself. Also, shorter postpartum hospital stays have made it difficult for nurses to assess and to assist in managing postpartum fatigue. Fatigue begins soon after delivery and becomes progressively more severe. In a study of 259 newly delivered mothers, mothers identified fatigue as being a problem by 36 hours postpartum and as being an even greater problem 6 weeks later (Milligan, Parks, & Lenz, 1990). The combination of the potential effects of shorter hospital stays and the progressive nature of postpartum fatigue points to a need for women to learn techniques for managing their fatigue. In an effort to help women learn self-management of postpartum fatigue, two Clinical Methods

Evaluating physician efficiency in hospitals: A multivariate analysis of best practices

This paper reports on a six-month study of the clinical efficiency of 36 physicians in a single hospital. Both technical and scale efficiency are analyzed using Data Envelopment Analysis (DEA) and a multi-factor Tobit analysis is conducted to see which variables are associated with higher levels of physician performance. DEA identifies 24 inefficient physicians. The slack associated with these physicians supports the hypothesis that a substantial amount of money could be saved if every physician practiced medicine as efficiently as the most competent physicians. The Tobit analysis revealed two categories of technically efficient physicians: those who (1) belong to a health maintenance organization (HMO), or (2) specialize by diagnostic related groups (DRGs). Estimates of most productive output scale suggest that locally decreasing returns to scale set in at higher output levels for physicians who treat higher proportions of high severity patients. The results illustrate how blending DEA with censored regression can sharpen an analysis of best practices.

HOSPITAL RESOURCE PLANNING: CONCEPTS, FEASIBILITY, AND FRAMEWORK

The mantra of health care reform in hospitals in the United States and elsewhere, the spiralling costs of health care, and the development of diagnostic‐related groups (DRGS) that define health services as “products” are influencing the strategic role of operations planning and control in hospital delivery systems. We developed a new operations planning and control system that we call “Hospital Resource Planning” (HRP). This system is based on the concept of DRGS and the familiar concept of manufacturing resources planning (MRP‐II). TO determine the potential feasibility of HRP, we gathered longitudinal data from two hospitals, one 300‐bed community hospital and one 1,100‐bed teaching hospital. Our exploratory study indicated that while the concept of MRP‐II can be transferred to hospitals, the traditional MRP logic has shortcomings. HRP advances prior research in three ways: (1) consideration of DRGS as products with a bill of resources structure that simultaneously incorporates both capacity and materials resources, (2) implementation of a hospital‐wide (versus a functional) planning and control'system, and (3) gross‐to‐net requirements logic based on notions of treatment staging. Other feasibility issues that we addressed pertain to a stochastic bill of resources, trends toward hospital product standardization, and the coordination of a central planning system with decentralized decision making. The paper concludes with a description of areas for future research.

The effect of fixed payment on hospital costs.

New Medicare regulations have replaced the cost-based system of reimbursement of capital expenditures by hospitals with a fixed payment per case based on assigned diagnostic-related groups. For the first time, hospitals must pay the governmental share of their capital costs. At the same time, overall reform points toward more capitation or fixed payments from all payers. This article discusses possible responses to legislative and competitive reforms by hospital management and the resulting effectiveness of the changes. To identify the potential effect of capital payment reform, we highlight some of the key provisions and assumptions of the new regulations, discuss the management implications of a changed capital payment system, and explore alternative models of hospital investment behavior in a world where one price for services for all buyers is a probable scenario.

Hospital inpatient costs resulting from road crashes in Western Australia

The purpose of this study was to estimate the inpatient costs of road crashes in Western Australia, and to investigate factors relating to casualties and their injuries that affect the hospital costs resulting from road crashes. All road crash casualties who were injured severely enough to be hospitalised in Western Australia in 1988 were included. A casemix classification system was used to classify patients into diagnostic related groups. Hospital costs were assigned to individual patients on the basis of their diagnostic related group and length of hospital stay. The annual cost of hospital treatment for road crash casualties was estimated as $13.9 million, and 33 per cent of this was incurred by those with lower extremity injuries and 27 per cent by those with head injuries. Hospital costs per casualty ranged from an average of $1388 for those sustaining minor (Abbreviated Injury Scale severity score of 1 or 2) spinal injuries to $16,580 and $33,424, respectively, for those sustaining severe (Abbreviated Injury Scale severity score of 4 or 5) head and spinal injuries. A multivariate analysis of variance revealed the following factors as having a significant independent effect on the hospital inpatient costs of road crash casualties: type of hospital (teaching or nonteaching), body region of injury, injury severity level and road user group. There were also significant interaction effects between different factors. Since hospital inpatient costs vary considerably across factors, using average cost data in the specific economic evaluation of road safety interventions for groups of road users is inappropriate.