German DRG Research Articles

Correlation between severity of disease and reimbursement of costs in neonatal and paediatric intensive care patients

The aim of the present study was to investigate the correlation between neonatal, paediatric and adult disease severity scores and reimbursement by health insurances. The setting was a university hospital's neonatal intensive care unit (NICU) and paediatric intensive care unit (PICU). We performed a prospective study of all patients admitted over the 3-month study period. Data collected included five scoring systems to predict mortality or to quantify disease severity (Paediatric Index of Mortality [PIM], Paediatric Risk of Mortality [PRISM], Simplified Acute Physiological Score [SAPS], Score for Neonatal Acute Physiology [SNAP], Therapeutic Intervention Scoring System [TISS]) on a daily basis, the total reimbursement as calculated by the grouper according to the German diagnosis-related groups (DRG) system, age of the patient, length of stay (LOS), International Classification of Diseases (ICD)-10 and DRG diagnosis. Our intention was to determine the correlation between different neonatal, paediatric and adult scores (PIM, PRISM III, SAPS-II, SNAP, Core-10-TISS), and reimbursement by the health insurance on the basis of the German DRG system in its 2005 and 2007 version. No positive correlation between any score applied and reimbursement by the health insurance could be identified. Reimbursement was positively correlated to the length of hospital stay. Positive correlations could also be shown for some of the scores among each other. We conclude that other scoring systems or measures of disease severity urgently need to be established to terminate the chronic underfunding of paediatric intensive care medicine in the developed countries.

Die HNO-Heilkunde, Kopf- und Hals-Chirurgie im G-DRG-System 2008

Further developments in the German DRG system have been incorporated into the 2008 version. For ENT medicine and head and neck surgery significant changes concerning coding of diagnoses, medical procedures and concerning the DRG-structure were made. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2008 focussed on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities. The G-DRG system has gained in complexity again. High demands are made on correct and complete coding of complex ENT and head and neck surgery cases. Quality of case allocation within the G-DRG system has been improved. For standard cases quality of case allocation is adequate. Nevertheless, further adjustments of the G-DRG system especially for cases with complex neck surgery are necessary.

Orthopädie und Unfallchirurgie im G-DRG-System 2008

The German DRG (diagnosis-related groups) system has been modified and updated into version 2008. For orthopedic and trauma surgery significant changes concerning coding of diagnoses, medical procedures and the DRG structure were made. The modified version has been analyzed in order to ascertain whether the DRG system is suitably qualified to fulfill the demands of the reimbursement system or whether further improvements are necessary. Analysis of the severity of relevant side-effect diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 was carried out based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2008 focused on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities. G-DRG system has become even more complex and the new regulations have also resulted in new problems associated with complications.. High demands are made on correct and complete coding of complex orthopedic and trauma surgery cases. Quality of case allocation within the G-DRG system has been improved. Nevertheless, further improvements of the G-DRG system are necessary, especially for cases with severe injuries.

Terminologie der Blasenfunktionsstörungen und Kodierung im ICD-10-GM-Katalog

The terminology of lower urinary tract dysfunction was recommended by the AWMF and the German Society of Urology in 2004. However, there is no transfer of this terminology to diagnoses according to the classification of the ICD-10-GM catalogue. This catalogue is of major relevance for remuneration of inpatient and outpatient treatment in the German diagnosis-related groups (DRG) system. This article presents a table showing the correspondence between the current terminology and the ICD-10-GM classification. The correct coding can change the DRG remuneration by a factor of 2 to 3.

Prevalence estimation of anorectal malformations using German diagnosis related groups system

Without major registries, true prevalence of rare congenital diseases is not known. Estimations for occurrence of anorectal malformation (ARM) are based on monitoring centers and epidemiological studies. The new German economical system for payment of inpatient care (G-DRG) obligates the report of each hospitalization, including diagnoses and procedures. These codes and classifications originally developed for morbidity statistics are now misused for economical purposes. Is there an epidemiological use? We present a new method to estimate national wide prevalence rate of congenital malformations exemplarily for imperforated anus. Due to the new German DRG-system, treatment data collections of the years 2002-2005 are freely accessible. This method is applicable if a life saving surgery is mandatory for newborns and has to be ciphered by specific codes. Overall, in German hospitals 1,012 children below 1 year of age are surgically treated with a reconstructive anorectal surgery during the period of 4 years. In the same time 2,817,388 babies are born in Germany. Hence the national wide prevalence rate is about 3.6 (95% CI: 3.4-3.8) per 10,000 or 1:2,784 for all different types of anal atresia requiring surgery. Main ICD-10 diagnosis Q42 was given twice this rate, probably due to at least two hospitalizations in the newborn period. The economic data of the G-DRG system can be used to estimate yearly prevalence of some rare congenital diseases in Germany, in case of specific surgical procedures. It may be a useful supplement to smaller regional registries because of larger size. Further calculations for other epidemiological questions have to be faced.

Kosten und Komplikationen der Materialentfernung

Implant removal procedures are among the most frequently performed orthopaedic operations. Since they can have potentially severe complications, relative indications for such procedures have to be thoroughly considered especially when patients have no symptoms. Apart from such general complications as infection, the possibility of refractures, nerve lesions, pain arising for the first time after surgery and incomplete hardware removal must be borne in mind. The fixed-angle implants in particular have given rise to a new type of complications following hardware removal. These procedures cannot therefore be recommended except for symptomatic patients. In some countries, however, implant removal operations are the second most frequently performed group of orthopaedic-traumatological procedures, so that in addition to their significance for the national economy these procedures could increase case numbers and—depending on numerous variables—also enhance revenue. When the German DRG system is used as the basis for invoicing revenues can be optimised when operations are done fast and with few complications.

“Fast-track” rehabilitation for elective colonic surgery in Germany—prospective observational data from a multi-centre quality assurance programme

The results of "Fast-track" colonic surgery in an unselected population outside of specialised units has been unknown yet. Data from 24 German hospitals performing "Fast-track" rehabilitation as the standard peri-operative care for patients undergoing elective colonic resection were collected in a prospective multi-centre study conducted between April 2005 and September 2006 to evaluate local and general morbidity. One thousand and forty-seven patients undergoing elective "fast-track" colonic resection were included. Compliance to essential parts of "fast-track" rehabilitation was high (epidural analgesia 86,6%, early oral feeding and mobilisation on the day of surgery 85.5 and 85.4%). Surgical morbidity was observed in 148 patients (14.1%) and general morbidity in 95 patients (9.1%), while mortality was 0.8%. Predefined discharge criteria were met within 5 (1-83) days after surgery, but because of economical restraints in the German DRG system, patients were discharged only after 8 (3-83) days. Re-admission rate was 3.9%. "Fast-track" rehabilitation for elective colonic resection was safe and feasible in German hospitals of all sizes and yielded a low general morbidity and re-admission rate. Post-operative recovery was enhanced, but discharge from hospital was delayed because of economical reasons.

Ökonomische Effekte der Standardisierung in der modernen Wundversorgung

Despite the advantages of modern wound management, it is still employed too rarely because of higher costs and lack of information available to the medical staff. At the University Hospital Jena, the assortment of hydroactive wound dressings has been optimized, in order to increase acceptance and attain cost advantages. The defined target sizes were differentiated according to economic and qualitative parameters. The economic parameters included the reduction in the total costs for wound management, adjusted for the case mix and the number of cases. Among the qualitative parameters were reducing the number of suppliers and the number of orders outside the standard offerings. Via standardization, the average expenses per case for hydroactive wound applications could be reduced by 10.3% and the average expenses per weighted German DRG by 15.9%. As a result of the reorganization of the assortment, the number of suppliers was reduced by 57.1% and two main and one secondary supplier were designated. The number of orders outside the standard assortment was reduced from 173 to 21 (87.8%). The standardization of the assortment of hydroactive wound applications has led to an increase in procedural efficiency and effectiveness at the University Hospital Jena, in addition to a reduction in the cost of material and in the number of suppliers.

Bedeutung eines Codierbeauftragten Facharztes für die Abbildungsqualität und Vergütung einer orthopädischen Universitätsklinik im G-DRG-System 2005

In the year 2005 the German DRG system underwent further differentiation in many areas compared to previous years. The effects of an improved coding quality by a specifically trained orthopaedic surgeon (KBFA) at an orthopaedic university department are analysed. In a closed sample of 1 277 cases the following parameters were documented after primary coding at discharge and after the final coding by the KBFA: main diagnosis, number of additional diagnoses and procedures, the resulting G-DRG, PCCL, cost weight and revenues. These data were analysed for statistically significant differences and correlations. The final coding by the KBFA caused a significant (p<0.001) increase in the number of diagnoses and procedures. The intervention of the KBFA changed the DRG grouping in 34 % of the cases. The cost weight increased significantly and the case mix index raised by 0.26 in the complete sample, corresponding to an increased revenue of euro 62 per case and day. The establishment of a KBFA in an orthopaedic department improved the quality of revenue-relevant DRG coding and the reflection of the economic complexity level of the cases. Compared to other reports, an above-average increase of cost weight as well as specification depth for diagnoses and procedures was achieved.

Case allocation of extensive operations on head and neck within the German DRG system 2004–2007

Hintergrund Bei Einfuhrung des DRG-Systems bestanden erhebliche Zweifel an einer sachgerechten Abbildung der Patienten mit grosen Eingriffen an Kopf- und Hals. Daher wurden grose Anstrengungen zur Ausdifferenzierung dieser Fallgruppe unternommen. Ziel der vorliegenden Arbeit war es, zu analysieren, inwieweit durch die Ausdifferenzierung des G-DRG-Systems eine sachgerechte Abbildung erreicht werden konnte.

ENT and head and neck surgery in the German DRG system 2007

The German DRG system has been further developed into version 2007. For ENT and head and neck surgery, significant changes in the coding of diagnoses and medical operations as well as in the the DRG structure have been made. New ICD codes for sleep apnoea and acquired tracheal stenosis have been implemented. Surgery on the acoustic meatus, removal of auricle hyaline cartilage for transplantation (e. g. rhinosurgery) and tonsillotomy have been coded in the 2007 version. In addition, the DRG structure has been improved. Case allocation of more than one significant operation has been established. The G-DRG system has gained in complexity. High demands are made on the coding of complex cases, whereas standard cases require mostly only one specific diagnosis and one specific OPS code. The quality of case allocation for ENT patients within the G-DRG system has been improved. Nevertheless, further adjustments of the G-DRG system are necessary.

Introduction of diagnosis-related groups in Germany: evaluation of impact on in-patient care in a dermatological setting

German diagnosis-related groups (G-DRG) have been introduced in Germany as a reimbursement system for in-patient care. The aim of this study was to report data-based experiences from the introduction process and to evaluate the impact on in-patient dermatology. A quantitative analysis including clinical data from two large university centres of dermatology over a time period of 4 years (2003-06) has been performed. Characteristics and trends of case-mix index, number of cases, average age, length of stay (LOS), surgical and medical treatments and in-patient case groups were studied in detail. It was found that the case-mix index values increased after the introduction period, but subsequently declined on the initial value. At the same time, an increase of dermatological hospital admissions can be noticed parallel to a significant reduction of LOS (P < 0.001) and a moderate increase of average age (P < 0.001). Analysis of DRG assignment revealed an initial significant decline of surgical in-patient procedures and increasing medical treatments, however, without obvious long-term changes. Furthermore, a growing importance for dermatological oncology and inflammable skin diseases within the in-patient setting could be observed. The introduction of the G-DRG system in Germany induced changes in in-patient care affecting hospital admission rates, LOS and cases treated in an in-patient setting. In-patient activities have not been reduced with the DRG introduction; however, long-term interdisciplinary research approaches are needed to explore the future impact on health care providing and quality of health care in depth.

Kosten der patientenkontrollierten Analgesie (PCA) im Rahmen des postoperativen Schmerzmanagements in Deutschland

This systematic literature review was conducted to analyze the costs of postoperative patient controlled analgesia (PCA) in Germany. The literature search comprised the search criteria "therapeutic procedure", "postoperative pain management", the routes of administration "intravenous PCA" (PCIA) and "epidural PCA" (PCEA), as well as their corresponding costs and economic analyses. Due to differences in indications, calculated costs and medical expenses it was not possible to compare the results from the respective studies. A critical examination of benefits and costs of therapeutic options in hospitals has become necessary with the implementation of the German DRG compensation system. This has created a substantial need for the optimization of resources and processes. There is an enormous demand for research on the costs for PCA in Germany. The identification of cost-driving factors is necessary to determine saving potentials and thereby develop new technologies for postoperative analgesia.

Die Handchirurgie im G-DRG-System 2007

Hand surgery often needs only a short length of stay in hospital. Patients' comorbidity is low. Many hand surgery procedures do not need inpatient structures. Up until 2006 special procedures of hand surgery could not be coded. The DRG structure did not separate very complex and less complex operations. Specialized hospitals needed a proper case allocation of their patients within the G-DRG system. The DRG structure concerning hand surgery increased in version 2007 of the G-DRG system. The main parameter of DRG splitting is the complexity of the operation. Furthermore additional criteria such as more than one significant OR procedure, the patients' age, or special diagnoses influence case allocation. A special OPS code for complex cases treated with hand surgery was implemented. The changes in the DRG structure and the implementation of the new OPS code for complex cases establish a strong basis for the identification of different patient costs. Different case allocation leads to different economic impacts on departments of hand surgery. Whether the new OPS code becomes a DRG splitting parameter has to be calculated by the German DRG Institute for further DRG versions.

Die Stichprobenprüfung nach § 17 c KHG - Erfahrungsbericht aus Krankenhäusern der Maximalversorgung in Hessen

Hospital billing converted to "German diagnosis-related groups" (G-DRG) for in-patient treatment in Germany is reviewed, except in psychiatry where per-diems are still in use. Currently thousands of bills are sent to the Medical Service for scrutiny. In addition, the law relating to Hospital Financing (Krankenhausfinanzierungsgesetz, para. 17 c) provides for systematic checks on a random sample of bills from a given hospital. The Medical Service of the Social Security Health Insurance reports on the experience in the State of Hessen. Present regulations exclude from the random sample those bills that have already been presented for a check on a case by case basis. Excluding these cases from the random sample introduces a bias in an avoidable way. The present rule is contrary to valid conclusions from the random sampling and should be abolished.

DRG-Prüfergebnisse im Ländervergleich: MDK Baden-Württemberg und MDK Westfalen-Lippe

We report on the first detailed comparison of evaluation results regarding the correct billing in the G-DRG (German diagnosis-related group) system. For two Medical Review Boards of the Statutory Health Insurance Funds of comparable size (MDK Baden-Württemberg and MDK Westfalen-Lippe), we analysed consecutive expertises regarding correct billing according to section sign 275 SGB V, and the results were compared in terms of the frequency of DRG-relevant error codes, their relevance to revenue, and the question of error clustering (specific DRGs, primary diagnoses, etc.). The analysis comprised 51,010 individual expertises pertaining to billings of the year 2005 (admittance to hospital from January 1 to December 31, 2005). The proportion of disapproved cases was 38.5% in Baden-Württemberg and 44.6% in Westfalen-Lippe. Among these, errors to the disadvantage of the Health Insurance (incorrectly high) were 33.9% and 39.3%, respectively, and errors to the disadvantage of the hospitals (incorrectly low) were 4.6% and 5.3%, respectively. The resulting ratio (incorrectly high vs. low) was an identical 7.4 in both cases. Not only the most commonly rejected DRGs but also the primary and secondary diagnoses were similar in both cases, while the disapproved procedure codes showed a significant variability (analysis based on the respective 10 most common objections). We discuss the similarities and differences in these results and their possible causes, and demonstrate the cost relevance of this audit segment. Result comparisons of this type can yield insights into streamlining of the review practice of Medical Review Boards, as well as increase the efficiency and effectiveness of the selection of cases.

Unfallchirurgie und Orthopädie im G-DRG-System 2007

The German Diagnosis-Related Groups (DRG) System was further developed into its 2007 version. For orthopedic and trauma surgery, significant changes were made in terms of the coding of diagnoses and medical procedures, as well as in the DRG structure itself. The German Societies for Trauma Surgery and for Orthopedics and Orthopedic Surgery (Deutsch Gesellschaft für Unfallchirurgie, DGU; and Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, DGOOC) once again cooperated constructively with the German DRG Institute InEK. Among other innovations, new International Classification of Diseases (ICD) codes for second-degree burns were implemented. Procedure codes for joint operations, endoprosthetic-surgery and spine surgery were restructured. Furthermore, a specific code for septic surgery was introduced in 2007. In addition, the DRG structure was improved. Case allocation of patients with more than one significant operation was established. Further DRG subdivisions were established according to the patients age and the Patient Clinical Complexity Level (PCCL). DRG developments for 2007 have improved appropriate case allocation, but once again increased the system's complexity. Clinicians need an ever growing amount of specific coding know-how. Still, further adjustments to the German DRG system are required to allow for a correct allocation of cases and funds.

Das ovarielle Überstimulationssyndrom (OHSS) - eine Kostenanalyse

The introduction of the German DRG remuneration system in 2004 has resulted in many changes. The increased cost pressure is forcing many hospitals to improve their cost-effectiveness even more. An analysis of costs and earnings to assess the economic situation of different areas and improve revenues is indispensable. This review offers an economic assessment of the in-hospital treatment of OHSS patients in the gynecological clinic of the University Hospital Erlangen. It could be demonstrated that a suitably adapted treatment regime combined with optimized coding procedures can lead to a positive earnings situation.

Inkrementelle Kosteneffektivität der multifokalen Kataraktchirurgie

Supplementation of cataract patients with multifocal intraocular lenses involves an additional financial investment when compared to the corresponding monofocal supplementation, which usually is not funded by German health care insurers. In the context of recent resource allocation discussions, however, the cost effectiveness of multifocal cataract surgery could become an important rationale. Therefore an evidence-based estimation of its cost effectiveness was carried out. Three independent meta-analyses were implemented to estimate the gain in uncorrected near visual acuity and best corrected visual acuity (vision lines) as well as the predictability (fraction of patients without need for reading aids) of multifocal supplementation. Study reports published between 1995 and 2004 (English or German language) were screened for appropriate key words. Meta effects in visual gain and predictability were estimated by means and standard deviations of the reported effect measures. Cost data were estimated by German DRG rates and individual lens costs; the cost effectiveness of multifocal cataract surgery was then computed in terms of its marginal cost effectiveness ratio (MCER) for each clinical benefit endpoint; the incremental costs of multifocal versus monofocal cataract surgery were further estimated by means of their respective incremental cost effectiveness ratio (ICER). An independent meta-analysis estimated the complication profiles to be expected after monofocal and multifocal cataract surgery in order to evaluate expectable complication-associated additional costs of both procedures; the marginal and incremental cost effectiveness estimates were adjusted accordingly. A sensitivity analysis comprised cost variations of +/- 10 % and utility variations alongside the meta effect estimate's 95 % confidence intervals. Total direct costs from the health care insurer's perspective were estimated 3363 euro, associated with a visual meta benefit in best corrected visual acuity and near visual acuity of 5.1 lines (95 % confidence interval 3.8 - 6.4 lines) and 6.1 lines (4.7 - 7.5 lines), respectively, and a meta predictability estimate of 81 % (72 - 89 %). The mean MCER for best corrected visual acuity results became 659 euro per gained visual acuity line (sensitivity range 473 - 973 euro). For near visual acuity, a mean MCER of 555 euro (sensitivity range 404 - 787 euro) per gained visual line was found. In terms of incremental costs, multifocal cataract surgery implied an additional mean investment of 63 euro (sensitivity range 0 - 234 euro) per additionally gained near visual acuity line, and 5 euro (0 - 18 euro) per additionally gained percentage point in predictability, when compared to monofocal cataract surgery as the standard treatment. The meta-analysis on complication profiles revealed posterior capsule opacification (meta incidence 20 %) and vitreous loss (meta incidence 2 %) as the complications to be expected most frequently. The cost adjustment for expectable complication patterns after multifocal cataract surgery implied total direct costs of 3491 euro, resulting in marginal costs of 576 euro per line (sensitivity range 419 - 817 euro per line) gained in near visual acuity and 684 euro per line (491 - 1011 euro per line) gained in best corrected visual acuity. Bearing incremental costs of 63 euro per additionally gained vision line (near visual acuity) in mind, multifocal cataract surgery comprises a cost effective alternative to the monofocal standard treatment.

DRGs und Pflegesätze in der Psychosomatik: 2002-2005

Over the last years the use of diagnosis-related groups (G-DRG) was introduced into most areas of the German health care system, which led to changed compensation for departments outside the G-DRG system as well. We evaluated the development of revenues in 17 different psychosomatic departments over the last three years. Our analyses were based on official daily rates for each of the clinics included. If daily rates changed within one year, we used the average daily rate for that year. Together all departments provided 547 in-patient beds for the treatment of acute psychosomatic patients. With 85% occupancy all departments would achieve a revenue of 62.5 million euro in 2005, two million euro less than three years previously. Due to the introduction of the German DRG system their average income was reduced by approx. 3%. The loss was greater for psychosomatic departments at larger hospitals, which have a higher percentage of departments included in the G-DRG system. The introduction of the G-DRG system leads to reduced revenues for departments outside the G-DRG system, while performance was expected to remain at the same level and costs have increased. Thus, to ensure the spectrum of psychosomatic medicine as it is today, it has become increasingly important to demonstrate the real costs of treatment to political decision makers.