DRG System Research Articles

Влияние кверцетина на клиническое течение неалкогольного стеатогепатита и диабетической болезни почек на фоне комплексного лечения больных сахарным диабетом типа 2

Цель исследования — установление возможного влияния комплекса средств — метформина, розувастатина, эссенциальных фосфолипидов и кверцетина на клиническое течение неалкогольного стеатогепатита (НАСГ), диабетической болезни почек, сахарного диабета (СД) типа 2, а также на состояние липидного спектра крови, параметры компенсации углеводного обмена, степень инсулинорезистентности, которые являются факторами прогрессирования НАСГ и диабетической болезни почек. Материалы и методы. Проведенные исследования в динамике лечения у 60 больных НАСГ с СД типа 2 и диабетической болезнью почек I–III стадии, среди которых у 48 пациентов был установлен НАСГ легкой активности, а у 12 — умеренной активности. Коморбидным заболеванием у всех пациентов с НАСГ был СД типа 2 средней степени тяжести, у 15 человек он был в состоянии компенсации, у 45 — субкомпенсированный. Состояние углеводного обмена устанавливали по уровню гликемии натощак и через 2 часа после еды глюкозооксидазным методом, по содержанию в крови инсулина натощак (DRG System) методом иммуноферментного анализа, содержанию в крови гликированного гемоглобина с помощью стандартных наборов реактивов «Simko Ltd» (Львов). Результаты. Через месяц от начала терапии астеновегетативный синдром значительно меньшей интенсивности сохранялся лишь у одного человека (3,13 %) второй группы, тогда как в первой группе он оставался у 9 больных (32,1 %). В то же время у большинства больных второй группы исчезли ощущение тяжести и боль в правой подреберной области (соответственно у 31 (96,9 %) против 16 (57,1 %) в первой группе (р < 0,05), а также практически не беспокоили диспептические явления (24 больных второй группы (75,0 %) против 11 человек (39,3 %) в первой группе). Через месяц от начала лечения не было зарегистрировано клинических проявлений синдрома холестаза у 20 (62,5 %) больных второй группы и только у 10 больных (35,7 %) в первой группе (р < 0,05). Отмечено положительное влияние дополнительного к комплексной терапии назначения кверцетина на регрессию гепатомегалии, которая после лечения в течение одного месяца оставалась лишь у 5 лиц второй группы (15,6 %). Выводы. Комплексная терапия эссенциальными фосфолипидами, розувастатином, метформином в сочетании с кверцетином у лиц с коморбидными НАСГ, СД типа 2 и диабетической болезнью почек способствует устранению основных клинико-лабораторных симптомов обострения НАСГ, снижению интенсивности воспалительного процесса в печени, обратному развитию явлений стеатоза печени, способствует нормализации гликемии. Комплексная терапия с добавлением кверцетина достоверно способствовала повышению эффективности лечения диабетической болезни почек на фоне СД типа 2, уменьшению частоты выявления протеинурии, повышению скорости клубочковой фильтрации, снижению степени гиперкреатининемии.

Population health management in France: specifying population groups through the DRG system

BackgroundPopulation health management (PHM) by hospital groups is not yet defined nor implemented in France. However, in 2019, the French Hospitals Federation launched a pilot program to experiment PHM in five territories around five Territorial Hospital Groups (GHT’s). In order to implement PHM, it is necessary to firstly define the population which healthcare facilities (hospitals) have responsibility for. In the French healthcare system, mapping of health territories however relies mainly on administrative data criteria which do not fit with the actual implementation of GHT’s. Mapping for the creation of territorial hospital groups (GHTs) also did not include medical criteria nor all healthcare offers particularly in private hospitals and primary care services, who are not legally part of GHT’s but are major healthcare providers. The objective of this study was to define the French population groups for PHM per hospital group.MethodsA database study based on DRG (acute care, post-acute and rehabilitation, psychiatry and home care) from the French National Hospitals Database was conducted. Data included all hospital stays from 1 January 2016 to 31 December 2017. The main outcome of this study was to create mutually exclusive territories that would reflect an accurate national healthcare service consumption. A six-step method was implemented using automated analysis reviewed manually by national experts.ResultsIn total, 2840 healthcare facilities, 5571 geographical zones and 31,441,506 hospital stays were identified and collated from the database. In total, 132 GHTs were included and there were 72 zones (1.3%) allocated to a different GHTs. Furthermore, 200 zones were manually reviewed with 33 zones allocated to another GHT. Only one area did not have a population superior to 50,000 inhabitants. Three were shown to have a population superior to 2 million.ConclusionsOur study demonstrated a feasible methodology to define the French population under the responsibility of 132 hospital groups validated by a national group of experts.

Smoking cessation - achievable and effective

In hospital, effective smoking cessation can be organized through counselling, pharmacological aids and, above all, continuous care in outpatient structures following discharge. Pharmacological treatment has proven to be effective and safe with nicotine replacement therapy as well as varenicline. Counselling plus pharmacotherapy is more effective in combination than either therapy is on its own. To better implement structures medical societies in Germany are seeking adequate funding e. g. in the DRG system for hospitalised patients.There are obvious and relevant benefits in smoking cessation. Not only for the main tobacco-related diseases such as coronary heart disease or chronic obstructive pulmonary disease (COPD), positive effects of quitting on morbidity and mortality have been confirmed by high-quality meta-analyses. Furthermore, quality of life is increasing following cessation. Presently, smoking is found to be a significant risk factor for severe disease and mortality following coronavirus infection.Do e-cigarettes offer an alternative in smoking cessation? No. Animal and human data are suggesting toxic effects especially following longer use. The long-term effectiveness of e-cigarettes in tobacco cessation is still uncertain and epidemiologic data clearly point toward ineffectiveness. Furthermore, dual use with potentiation of the toxic effects is common. Therefore, e-cigarettes cannot be recommended for tobacco cessation.

Cost coverage for complex paediatric spinal deformities with preoperative halo traction-an economic problem?

Spinal surgery is largely reimbursed in adifferentiated manner via the DRG system. For treatments of complex paediatric deformities with increased pre and postoperative effort due to special treatment approaches, it seems that the costs for the treatment are not fully covered. All paediatric cases with surgical treatment of the spine that were treated in asingle spine centre from 2018-2020 were considered. The subgroup of patients with inpatient halo-gravity traction (halo group) before surgery was compared with all other cases treated in terms of economic and demographic factors. There were 86cases that were treated surgically without halo traction and 6 cases with halo traction. The groups did not differ significantly in age (p = 0.41) or Patient Clinical Complexity Level (PCCL, p = 0.76). The average length of hospital stay in the halo group was significantly longer than in the other cases (84.2 ± 40.1 d vs. 11.0 ± 6.4 d; p = 0.001). Due to DRG grouping and long-stay surcharges, the mean revenue per case was significantly higher in the halo group than in the other cases (€ 63,615 ± 45,138 vs. € 16,836 ± 9356) (p = 0.003). The contribution margin for the period of the long-term surcharges varied between 11,394 and 9766 €. The high additional costs due to the necessary medical devices of halo traction were not sufficiently reflected in the reimbursement. Paediatric spine surgery can be challenging in special cases. In particular, severe deformities of the spine may require additional procedures. The subgroup of patients requiring preoperative halo traction is not adequately compensated by the DRG system.

Patient safety during endoprosthetic training : Does the training of surgeons in primary hip arthroplasty at certified endoprosthesis centres lead to increased complications?

HintergrundZiel der Studie war die Untersuchung, ob sich das perioperative Outcome und operationsspezifische Prozessgrößen bei Patienten mit Hüftgelenksersatz signifikant verschlechtern, wenn die Operation durch einen unerfahrenen Operateur, assistiert durch einen erfahrenen Operateur, im Kontext eines zertifizierten Endoprothesenzentrums durchgeführt wird.Material und MethodenEs wurden 1480 Patienten eingeschlossen, die zwischen 2013 und 2016 bei primärer Koxarthrose mit einer primären zementfreien Hüfttotalendoprothese (HTEP) versorgt wurden. Die relevanten Daten wurden retrospektiv aus dem Krankenhausinformationssystem, dem Entlassungsbrief und aus dem EndoCert-Bogen dokumentiert. Die Operateure wurden nach ihrer Qualifikation in erfahrene (Senior, > 50 HTEP pro Jahr) und unerfahrene Operateure (Junior, < 50 HTEP pro Jahr) unterteilt. Anschließend erfolgte der Vergleich der erhobenen Daten anhand dieser Unterteilung.ResultateEs zeigte sich bei unerfahrenen Operateuren eine signifikante Verlängerung der Operationsdauer um 20,7 min (Senior 62,6 ± 20,4 min; Junior 83,3 ± 19,5 min; p ≤ 0,001), der Krankenhausverweildauer um 0,25 Tage (Senior 8,8 ± 0,9 d; Junior 9,0 ± 0,9 d; p ≤ 0,001) und eine Erhöhung der Transfusionshäufigkeit von Erythrozytenkonzentraten (Senior 0,6 ± 1,1 Stk.; Junior 0,9 ± 1,4 Stk.; p ≤ 0,001). Dagegen zeigte sich kein Unterschied bei perioperativen Komplikationen (p = 0,682) und beim perioperativen Blutverlust (Senior 1,3 ± 0,5 l; Junior 1,3 ± 0,5 l; p = 0,097). Zwischen Operationsdauer und Blutverlust bestand allerdings eine positive Korrelation (Senior r = 0,183; Junior r = 0,214; jeweils p ≤ 0,01).SchlussfolgerungDie Ausbildung von unerfahrenen Operateuren an einem zertifizierten Endoprothesenzentrum führt bei Assistenz durch erfahrene Operateure nicht zur Reduktion der Patientensicherheit mit vermehrten Komplikationen. Aufgrund der Operationszeitverlängerung kommt es allerdings zu einer Mehrbelastung der Kliniken im Wettbewerb mit nichtausbildenden Kliniken, die nicht im DRG-System abgebildet ist.

Outsourcing of nursing staff costs in psychiatry? : Asecondary data analysis of possible effects on the remuneration system in psychiatry

Nursing staff were excluded from the German DRG system for somatic hospital treatment and will be funded separately in the future. In psychiatry and psychosomatic medicine, binding personnel requirements have been defined but there has been no regulation of how these personnel requirements are adequately financed. The objective of this study was to analyze the costs of inpatient psychiatry and psychosomatic medicine and to evaluate possible effects of funding nursing staff separately. This analysis is based on aggregated daily treatment costs of selected hospitals (data year 2018), which annually submit their performance and cost data to the Institute for the Hospital Remuneration System (InEK) for the empirical further development of the remuneration system. Nursing staff represent the largest cost factor in inpatient psychiatry and psychosomatic medicine. Excluding nursing staff drastically reduces the variance of psychiatric DRG renumeration and even exceeds its proportion of the total costs. After outsourcing nursing costs, psychiatric DRGs achieve only avery limited cost separation. The binding personnel requirements necessitate adequate financing of nursing staff. This raises the debate about the further development of psychiatric remuneration. The question arises as to whether the effort associated with using the psychiatric DRG system justifies its usefulness as an instrument for budgeting when core functions such as cost separation are only given to alimited extent. Alternative approaches to budgeting should also be examined for putting costs and benefits in abetter ratio.

Inpatient Treatment - a Matter of Social Background in Germany

Hospital financing in Germany is based on the principle of dual financing: the operating costs of the hospitals, i.e. all costs that arise for treating patients, are financed by the health insurance companies. The investment costs, however, are financed by the federal states. The remuneration of the hospitals by the health insurance companies is based on the DRG system, which is a flat-rate billing system in which inpatient hospital treatments are billed as flat-rate fees, largely regardless of the length of the patient's stay. The DRG system is currently the subject of criticism because it makes it more difficult for children's clinics to cover costs, especially in pediatrics. On the basis of hospital billing data, there is a connection between the socio-economic status of a family and the likelihood of hospitalization in the event of a child's illness. The likelihood of inpatient treatment for certain pediatric diseases is significantly higher in economically weaker federal states. A proportionately higher inpatient treatment capacity is available in the affected federal states for this higher need. Should the poor financial situation of the federal states lead to the number of beds being rationed, the quality of care will deteriorate, especially for these children.

Economic aspects of interdisciplinary plastic surgery: change in Diagnosis-Related Groups (DRG) due to procedures of reconstructive microsurgery

Advances in reconstructive microsurgery have led to significant improvements in the surgical care of complex interdisciplinary cases. At the same time, however, this also increases the resource expenditure of the plastic surgeon involved. This study aimed to analyse the relationship between increase in revenue and resource expenditure in reconstructive microsurgery at a university hospital of maximum care with regard to the treatment of interdisciplinary patients. In 2018 and 2019, all cases of interdisciplinary cooperation were followed up at one location of a plastic surgery department of a university clinic. The interdisciplinary surgical cases were identified from the collective and evaluated prospectively with regard to inpatient treatment days, surgical resource expenditure and economic development (DRG before and after microsurgical reconstruction). In 2018 and 2019, a total of 68 free microsurgical flaps were performed in 64 interdisciplinary cases. 62 of these cases met the criteria for interdisciplinary surgical treatment. Considering the contribution of plastic surgery to the economic development and the associated resource expenditure, there is a significant increase in all parameters (p < 0.0001). Thus, the Case Mix Index (CMI) rose by 20.2 %, inpatient treatment days by 79.1 %, the number of surgical interventions by 62.4 %, cumulative incision-suture time by 131.4 % and total surgeon hours by 75.4 %. Reconstructive microsurgical procedures lead to a significant increase in revenue in interdisciplinary surgical cases. However, a significant increase in resource consumption is observed as well. Moreover, these additional costs are not always adequately reflected in the revenue of the DRG. This especially applies to DRGs with a high initial cost weight. To ensure modern, individual, patient-oriented and guideline-compliant patient care, there is, therefore, an urgent need to adapt the (G-)DRG system to the additional resource consumption. In addition, in the case of interdisciplinary surgical cases, a clear internal cost allocation must be carried out in accordance with the surgical resource expenditure.

Incentives for Multimodal Treatment-first Step Towards Pay for Quality (P4Q) for Chronic Care: Health Services Research from Germany

Background: Pay for Quality (P4Q) is being discussed as an incentive to ensure high quality standards despite cost pressure in healthcare. However, P4Q can also have adverse effects, and the evidence for its effectiveness is limited, especially regarding chronic conditions and multimorbidity. For the treatment of the latter, specific evaluation criteria were defined. Whether these are feasible in the context of costs and remunerations is analyzed in this study using the German DRG system as an example. The aim is to show conditions under which P4Q can be effective. Methods and Results: Costs and remuneration for hospitals were compared for an exemplary geriatric indication, with and without complex treatment. Doing so, cost weights were shown to be more than triple for the latter. The results are applicable to health care systems with P4Q or similar approaches. Conclusion: Introducing complex treatments poses higher and costly demands regarding structure, processes, and interdisciplinary cooperation in organizations. Additional average costs can be calculated by comparison to regular treatment. Covering the extra costs creates the necessary conditions for P4Q and makes the implementation of complex treatments more likely. As high standards have to be guaranteed for complex treatments and patient satisfaction rises when these are introduced, quality improvements can be assumed. This study can inform Health policy (incentive models) medical societies, give impulses for quality management, and healthcare research (patient-oriented health, e.g. consumer-driven health care, shared decision-making). Future studies should report patient-related outcomes and investigate further diagnoses.

Rationale of the levels of intensity and differentiated cost of labor costs of doctors in the hospital

Introduction: Due to the fact that Ukraine has not formally established tariffs for medical services and their complexity factors and the doctor’s remuneration system continues to exist on the basis of the “equalization” principle, we propose a scientifically based mechanism for determining the rate of labor intensity of hospital doctors and adequate the level of increase salary in accordance with the DRG. The purpose of the study: Because of, the level of labor of residents of the inpatient departments of the inpatient department of health facilities of the II and III levels is not the same, then based on the analysis of the number of treated patients in accordance with the DRG, the degree of complexity of the disease, their score, determine the level of labor intensity of doctors and real the size of their wages. Materials and methods: Based on the recommendations of the doctoral dissertation and a number of innovative medical and economic standards, analysis of a significant number of otolaryngologicalpatients, the use of the CSG, DRG system, the distribution of patients with a degree of complexity, their score, the algorithm for applying the above organizational standards, criteria and standards, and the use of timing. The technology of determining the individual level of the doctor’s labor intensity factors and an adequate level of its material stimulation has been developed. Results: Recommended technologies for using the aforementioned prerequisites, the need to create appropriate computer programs to simplify the analysis of individual doctors' work results, using the formulas presented in the article made it possible to determine both the degree of workload for a doctor and the level of possible increase in his salary. Conclusions: The algorithm for determining the coefficient of labor intensity of doctors and the mechanism for calculating the real cost of their labor in the treatment of specific patients of varying degrees of complexity can be used as a technological matrix for doctors of other medical specialties, in the future it will increase the material incentives of the latter at least to the level of family doctors.

'Hip-in-a-Day'

In 2017, the average length of stay for primary hip replacement patients in Germany was 10.2 days. In our hospital, we have been able to reduce the length of stay in the last 10years to an average of 3.8days. Since September 2015, we offer the 'Hip-in-a-Day' program. This ultra-fast-track pathway consists of ahip arthroplasty procedure with thesame day discharge of awell-prepared and explicitly selected patient with maximum intensive interdisciplinary care. The aim is to present the philosophy, treatment principles and daily routine during the pre-, intra- and postoperative phase. The challenges in the German health care system will be discussed. From September 2015 to November 2019, we operated on 97patients (50 F: 47 M, ages: 43-77 years, ⌀55 years) who had undergone the Hip-in-a-Day pathway. All 97patients received general anesthesia. Surgery was performed via the direct anterior approach (DAA) to the hip. Patients stayed in the day clinic less than 24 h after surgery. Of these, 30patients were discharged on the day of surgery (⌀12 h stay), and 67patients left the clinic the day after the operation (⌀20 h stay). Due to integrated health-care contracts with health-care providers, we were eligible to receive bundled reimbursement for this patient population. All 97patients completed the Ultra-Fast-Track pathway and were able to meet the discharge criteria within 24 h after surgery. 96of the 97(98.9%) patients were able to complete Hip-in-a-Day without readmission. One patient had to undergo revision surgery after 10days due to cup loosening. All patients (100%) were very satisfied with the routine of the day and the fast discharge from the hospital. The aim of Hip-in-a-Day is to discharge patients within 24 h after surgery. The implementation of the setup at the day clinic is intensive interdisciplinary care of all participating departments, as well as the three cornerstones of anesthesiological management, minimally invasive surgical techniques and patient compliance. In our clinic, ultra-fast-track arthroplasty is routinely feasible and has produced great patient satisfaction. Statutory health-care providers should include short-stay hip arthroplasty into the DRG system, so that this care concept can be reimbursed and practiced nationwide in Germany.

Managerial workarounds in three European DRG systems.

Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy. We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N=154), analysis of policy documents (N=111) and an action learning set, began in 2010-12, with additional data collection from key informants and administrative documents continuing in 2018-19 to supplement and update our findings. Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load 'ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed 'floor' volume. Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the 'managerial workaround' still further. In the case of DRGs, the managerial workarounds were instances of 'constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the 'managerial workaround'. Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection. So far as we are aware, no other study presents and tests the concept of a 'managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

Do We Really Know How Much the Covid-19 Pandemic Affected the Surgical Practice in Northern Italy? A Multi-Center Comparative Study and Cost Analysis.

Background: The Covid-19 pandemic in Northern Italy has slowed down the clinical surgical activity. A system of hub and spoke hospitals was set up to take care of oncological patients with the consequent almost complete abolition of the elective surgical activity for non-oncological pathologies. Methods: We retrospectively analyzed the surgical volumes of 4 different non academic general hospitals in Lombardy belonging to 4 different provinces. The quarter March April May 2019 was compared with the same period of 2020. All different procedures were listed. The cost analysis was performed using the DRG system. Results: In the four hospitals involved the surgical procedures reduced from 1903 to 350 with a drop of the 81.6%. Procedures for cancer from 403 to 161 with a drop of 60.1%. Procedures for benign disease from 1310 to 118 with a drop of the 91%. Emergencies from 190 to 71 with a drop of the 62.6%. State refund for the procedures performed from 6.708.023 to 1.678.154 with a drop of 75%. Conclusions: Elective surgery was dramatically impaired by the Covid-19 pandemic. Above all procedures for non oncological and non urgent patients were particularly affected. In view of a possible second wave of the pandemic, the surgical planning must select patients not only on onco logical criteria but rather on clinical ones. An ad hoc hub and spoke hospitals pathway has to be implemented for benign surgical diseases by whoever is facing the Covid pandemic at its spike.

Advancements in the DRG system payment: an optimal volume/procedure mix model for the optimization of the reimbursement in Italian health care organizations

Advancements in the DRG system payment: an optimal volume/procedure mix model for the optimization of the reimbursement in Italian health care organizations

PDB51 PREVENTION AS A PUBLIC HEALTH MEASURE: LONG-TERM EFFECTIVENESS AND COST EFFECTIVENESS OF A POPULATION-BASED IODINE DEFICIENCY DISEASES PREVENTION PROGRAM

Iodine deficiency can lead to different diseases, such as goiter, stillbirth and mental impairment of newborns. A population-based prevention program may eliminate iodine deficiency, but might also come with harms, such as increasing the prevalence of hyperthyroidism. We aimed to evaluate the cost effectiveness of a population based prevention program for iodine deficiency disorders (IDD). We developed a state-transition open cohort model to project the health and economic consequences of an IDD prevention program (i.e., iodine fortification of salt) in a hypothetical population with moderate iodine deficiency in the German context. Model parameters were derived by literature reviews, experts’ estimations or model calibration methods. Direct medical and non-medical costs were included (Euro 2018). Costs were derived from different sources: German DRG System, official medical fees, and Lauer Taxe. Indirect costs were considered in an additional analysis. We compared incremental life years (LY), incremental quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER) of prevention and no prevention. Health effects and costs were discounted at 3% annually. Model validation was performed. We analyzed three different scenarios: (1) open cohort over a time horizon of 120 years; (2) newborn cohort over their lifetime; (3) current live population over their lifetime, without consideration of new births. Additionally, we performed multiple one-way sensitivity analyses. In all three scenarios, the prevention was dominant compared to no prevention. Increments in quality-adjusted life expectancy ranged from 0.04 to 0.16 QALYs per person (0 to 0.01 LYs). For the currently live population in Germany (82,792,351), 0.04 QALYS amount to 3,311,694 QALYs gained. Cost savings ranged from EUR 522 to 14,624 per person. The prevention program remained dominant in most of the sensitivity analyses. Prevention of IDDs with iodine fortification of salt could be a cost-effective public health intervention for a moderately iodine deficient population.

Refining risk adjustment for bundled payment models in cervical fusions—an analysis of Medicare beneficiaries

BACKGROUND CONTEXTThe current Bundled Payment for Care Improvement model relies on the use of “Diagnosis Related Groups” (DRGs) to risk-adjust reimbursements associated with a 90-day episode of care. Three distinct DRG groups exist for defining payments associated with cervical fusions: (1) DRG-471 (cervical fusions with major comorbidity/complications), (2) DRG-472 (with comorbidity/complications), and (3) DRG-473 (without major comorbidity/complications). However, this DRG system may not be entirely suitable in controlling the large amounts of cost variation seen among cervical fusions. For instance, these DRGs do not account for area/location of surgery (upper cervical vs. lower cervical), type of surgery (primary vs. revision), surgical approach (anterior vs. posterior), extent of fusion (1–3 level vs. >3 level), and cause/indication of surgery (fracture vs. degenerative pathology). PURPOSETo understand factors responsible for cost variation in a 90-day episode of care following cervical fusions. STUDY DESIGNRetrospective study of a 5% national sample of Medicare claims from 2008 to 2014 5% Standard Analytical Files (SAF5). OUTCOME MEASURESTo calculate the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day reimbursements for patients undergoing cervical fusions under DRG-471, DRG-472, and DRG-473. METHODSThe 2008 to 2014 Medicare SAF5 was queried using DRG codes 471, 472, and 473 to identify patients receiving a cervical fusion. Patients undergoing noncervical fusions (thoracolumbar), surgery for deformity/malignancy, and/or combined anterior-posterior fusions were excluded. Patients with missing data and/or those who died within 90 days of the postoperative follow-up period were excluded. Multivariate linear regression modeling was performed to assess the independent marginal cost impact of DRG, gender, age, state, procedure-level factors (including cause/indication of surgery), and comorbidities on total 90-day reimbursement. RESULTSFollowing application of inclusion/exclusion criteria, a total of 12,419 cervical fusions were included. The average 90-day reimbursement for each DRG group was as follows: (1) DRG-471=$54,314±$32,643, (2) DRG-472=$28,535±$17,271, and (3) DRG-473=$18,492±$10,706. The risk-adjusted 90-day reimbursement of a nongeriatric (age <65) female, with no major comorbidities, undergoing a primary 1- to 3-level anterior cervical fusion for degenerative cervical spine disease was $14,924±$753. Male gender (+$922) and age 70 to 84 (+$1,007 to +$2,431) was associated with significant marginal increases in 90-day reimbursements. Undergoing upper cervical surgery (−$1,678) had a negative marginal cost impact. Among other procedure-level factors, posterior approach (+$3,164), >3 level fusion (+$2,561), interbody (+$667), use of intra-operative neuromonitoring (+$1,018), concurrent decompression/laminectomy (+$1,657), and undergoing fusion for cervical fracture (+$3,530) were associated higher 90-day reimbursements. Severe individual comorbidities were associated with higher 90-day reimbursements, with malnutrition (+$15,536), CVA/stroke (+$6,982), drug abuse/dependence (+$5,059), hypercoagulopathy (+$5,436), and chronic kidney disease (+$4,925) having the highest marginal cost impacts. Significant state-level variation was noted, with Maryland (+$8,790), Alaska (+$6,410), Massachusetts (+$6,389), California (+$5,603), and New Mexico (+$5,530) having the highest reimbursements and Puerto Rico (−$7,492) and Iowa (−$3,393) having the lowest reimbursements, as compared with Michigan. CONCLUSIONSThe current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost variation seen within 90-day reimbursements. Under the proposed DRG-based risk adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions), and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.

The continuous downgrading of malnutrition in the German DRG system: possible effects on the treatment of patients at risk for malnutrition.

It has been internationally recognized that malnutrition is an independent risk factor for patients' clinical outcome. A new mandatory fixed price payment system based on diagnosis-related groups (G-DRG) went into effect in 2004. The aim of our study was to demonstrate the importance of carefully coding the secondary diagnosis of "malnutrition" in the G-DRG system and to highlight how the economic relevance of malnutrition in the G-DRG system has changed from 2014 to 2016. 1372 inpatients at the Berufsgenossenschaftliche Unfallklinik (Trauma Center) in Tübingen were screened for the risk of malnutrition using Nutritional Risk Screening (NRS-2002). Patient data were compared with the NRS values collected during the study and a case simulation was carried out separately for each year. We used the codes E44.0 for NRS = 3 and E43.0 for NRS > 3. The ICD codes were entered as an additional secondary diagnosis in the internal hospital accounting system DIACOS to determine possible changes in the effective weight. In 2014 the highest additional revenue by far was calculated by coding malnutrition. For the 638 patients enrolled in the study in 2014, we were able to calculate an average additional revenue per patient coded with malnourishment of €107. In 2016, we were unable to calculate any additional revenue for the 149 patients enrolled. Although it is well known that malnutrition is an independent risk factor for poor patient outcomes, nationwide screening for a risk of malnutrition when patients are admitted to a hospital is still not required. For this reason, malnutrition in German hospitals continues to be insufficiently documented. Due to the continuous downgrading of diagnosis-related severity (CCL) of malnutrition in the G-DRG system in trauma surgery patients, it is no longer possible to refinance the costs incurred by malnourished patients through the conscientious coding of malnutrition. We assume that the indirect positive effects of nutritional interventions will have to be taken into account more in the costing calculations and possibly lead to indirect cost compensation.

Fast track strategies in hip arthroplasty

Fast track arthroplasty is becoming increasingly accepted in German-speaking countries. By optimizing treatment processes fast track programs promise faster recovery, increased patient satisfaction, quality improvement and reduction in the length of hospital stay. The philosophy and treatment principles of fast track hip arthroplasty during the pre, intra and postoperative phase are described in the light of the current body of evidence. The challenges concerning fast track arthroplasty within the German health system are discussed. Besides presenting our own data concerning apatient seminar and an opiate saving pain treatment, the most relevant literature related to fast track hip arthroplasty from apubmed search is discussed. Fast track concepts can only be successfully implemented through close interdisciplinary team work. Preoperatively, apatient seminar can help to prepare patients better for surgery. Postoperatively, early mobilisation and pain treatment play acentral role, whereat aclear reduction in opiate application can be achieved. Fast track hip arthroplasty makes rethinking with respect to traditional treatment principles necessary and demands ahigh degree of interdisciplinary team work. Particularly, as result of the specifics of the health system (DRG system and stationary rehabilitation), anationwide establishment in Germany has not taken place so far.

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.

The Austrian DRG-system: Insights from the first 2 decades

ISSUE: Austria was amongst the first European countries introducing a DRG-based hospital payment system in 1997. Initially, the groups were based on 476 diagnoses related groups for non-surgical admissions and 374 procedure related groups. The DRGs are granted for any case between a distinct range of the length of stay. *** DESCRIPTION OF THE PROBLEM: While intended to decrease average length of stay (ALOS) as well as hospitalisation rates, Austria only experienced decreasing ALOS in the first 10 years of the DRG-system from 8.3 days in 1997 to 6.8 days in 2007. Hospitalisation rates, however, continued to increase from 23 discharges per 100 inhabitants to 26.1 discharges in 2007 albeit initial high rates. Overall, concerns on the effectiveness of DRGs as an appropriate payment system increased amongst policy makers resulting in an evaluation ten years after its introduction. *** RESULTS: Even though the evaluation did not propose any immediate measures it increased the awareness of actively adapting the DRG system as well as capacity planning in order to provide the right incentives. In 2006, the regions were put in charge of detailed capacity planning at hospitals level making them accountable for structural health reforms. Day cases were increasingly incentivised in the DRG system and with the health reform 2013 thresholds were set up as minimum day case rates for various procedures. The 2013 reform brought also the development of a DRG system for ambulant services provided in hospital outpatient clinics. Overall, hospitalisation rates started to decrease from 2008 onwards from 26.3 discharges to 23 discharges in 2016 per 100 inhabitants. *** LESSONS: Although effective with regard to reducing ALOS DRG-based hospital payment systems do not necessarily promote lower hospitalisation rates. For the Austrian case with a high density of hospitals beds joint effort with regard to capacity planning and permanent adjustment of the DRG-system were necessary to reduce hospital admissions.