Impact Of Diagnosis-related Groups Research Articles

Impact of Diagnosis-Related Groups on Inpatient Quality of Health Care: A Systematic Review and Meta-Analysis.

The aim of this meta-analysis was to comprehensively evaluate the effectiveness of Diagnosis-related group (DRG) based payment on inpatient quality of care. A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science from their inception to December 30, 2022. Included studies reported associations between DRGs-based payment and length of stay (LOS), re-admission within 30 days and mortality. Two reviewers screened the studies independently, extracted data of interest and assessed the risk of bias of eligible studies. Stata 13.0 was used in the meta-analysis. A total of 29 studies with 36 214 219 enrolled patients were analyzed. Meta-analysis showed that DRG-based payment was effective in LOS decrease (pooled effect: SMD = -0.25, 95% CI = -0.37 to -0.12, Z = 3.81, P < .001), but showed no significant overall effect in re-admission within 30 days (RR = 0.79, 95% CI = 0.62-1.01, Z = 1.89, P = .058) and mortality (RR = 0.91, 95% CI = 0.72-1.15, Z = 0.82, P = .411). DRG-based payment demonstrated statistically significant superiority over cost-based payment in terms of LOS reduction. However, owing to limitations in the quantity and quality of the included studies, an adequately powered study is necessary to consolidate these findings.

Does DRG funding encourage hospital specialization? Evidence from the Italian National Health Service.

The impact of diagnosis-related group (DRG)-based funding has been analyzed along a wide range of dimensions. Its effects on hospital specialization, however, have been investigated only sparsely. This paper examines such effects in the context of the Italian National Health Service, where decentralization has produced a significant degree of variation in funding arrangements. To this end, a 9-year panel data set covering 762 Italian public and private hospitals was analyzed using a finite mixture model approach. Hospital specialization was measured by the internal Herfindahl-Hirschman Index. Three variables were introduced as proxies for the choices made by Italian Regions with respect to the development and use of their DRG systems. The best finite mixture model identified three groups of hospitals, two of which sizeable. Of these, one included nearly all public hospitals, while the other was composed almost exclusively of small and medium-sized investor-owned hospitals. Averagely, private and smaller hospitals showed a stronger tendency to specialize over time. The positive impact of DRG funding on the hospitals' propensity to specialize found only limited empirical support. Moreover, it emerged as comparatively much smaller for public hospitals vis à vis private ones.

Reinhard Busse: leader in Germany's health-system development

Reinhard Busse: leader in Germany's health-system development

Assessing the impact of DRGs on patient care and professional practice in Switzerland (IDoC) - a potential model for monitoring and evaluating healthcare reform.

The starting point of the interdisciplinary project "Assessing the impact of diagnosis related groups (DRGs) on patient care and professional practice" (IDoC) was the lack of a systematic ethical assessment for the introduction of cost containment measures in healthcare. Our aim was to contribute to the methodological and empirical basis of such an assessment. Five sub-groups conducted separate but related research within the fields of biomedical ethics, law, nursing sciences and health services, applying a number of complementary methodological approaches. The individual research projects were framed within an overall ethical matrix. Workshops and bilateral meetings were held to identify and elaborate joint research themes. Four common, ethically relevant themes emerged in the results of the studies across sub-groups: (1.) the quality and safety of patient care, (2.) the state of professional practice of physicians and nurses, (3.) changes in incentives structure, (4.) vulnerable groups and access to healthcare services. Furthermore, much-needed data for future comparative research has been collected and some early insights into the potential impact of DRGs are outlined. Based on the joint results we developed preliminary recommendations related to conceptual analysis, methodological refinement, monitoring and implementation.

Systematically evaluating the impact of diagnosis-related groups (DRGs) on health care delivery: A matrix of ethical implications

Swiss hospitals were required to implement a prospective payment system for reimbursement using a diagnosis-related groups (DRGs) classification system by the beginning of 2012. Reforms to a health care system should be assessed for their impact, including their impact on ethically relevant factors. Over a number of years and in a number of countries, questions have been raised in the literature about the ethical implications of the implementation of DRGs. However, despite this, researchers have not attempted to identify the major ethical issues associated with DRGs systematically. To address this gap in the literature, we have developed a matrix for identifying the ethical implications of the implementation of DRGs. It was developed using a literature review, and empirical studies on DRGs, as well as a review and analysis of existing ethics frameworks. The matrix consists of the ethically relevant parameters of health care systems on which DRGs are likely to have an impact; the ethical values underlying these parameters; and examples of specific research questions associated with DRGs to illustrate how the matrix can be applied. While the matrix has been developed in light of the Swiss health care reform, it could be used as a basis for identifying the ethical implications of DRG-based systems worldwide and for highlighting the ethical implications of other kinds of provider payment systems (PPS).

Ethical research on the implementation of DRGs in Switzerland - a challenging project

Diagnosis Related Groups (DRGs) are currently being introduced on a national scale as a prospective reimbursement scheme in Swiss in-patient hospital care, replacing any remaining retrospective day-rate arrangements. DRGs are expected to promote transparency and efficiency while helping to contain health care costs. The governmental decision to introduce DRGs has caused considerable controversy among different stakeholders, due to diverging appraisals of what will happen when DRGs are introduced as an economic management tool in Switzerland. The controversial discourse on DRGs is particularly interesting from an ethical point of view, since all arguments inevitably contain ethical considerations. In this paper we summarise the results of our exploratory ethical studies that have led to a larger research project funded by the Swiss National Science Foundation: "Impact of Diagnosis-Related Groups (DRGs) on patient care and professional practice" (IDoC). In section 1: 'Developing an understanding of the ethical issues at stake' we briefly explain how DRGs work, what the intended effects are, what the public is concerned about and what the scientific research tells us so far. In section 2: 'Developing an ethical framework for research on DRGs in Switzerland' we summarise the ethical issues and explain the ethical framework we will use in order to perform research on the complex issue of DRGs in Switzerland. Only once a profound understanding of the challenges exists can research on the ethical implications of DRGs be successful.

Healthcare regulation: Past, Present, and Future

Excessive regulation has created a formidable barrier for physicians to surmount when treating patients. This article examines the increasing intrusion by regulatory agencies--government and private--into the patient-physician relationship. The authors examine the history of healthcare policy leading to today's highly regulated approach to cost-containment. They trace the development of the emphasis on regulatory controls from 1900 to the present. Further, they examine in detail the specific impact of diagnosis-related groups, utilization review firms, and the Clinical Laboratory Improvement Amendments of 1988 on the patient-physician relationship. Diagnosis-related groups set the hospital administration as monitor of the patient-physician relationship. Utilization review firms insert themselves as another gatekeeper in decisions of appropriateness of care. The Clinical Laboratory Improvement Amendments causes laboratories to close, thereby restricting access to care. The reform movement would respect the patient-physician relationship and remove excessive regulation from this confidential interaction. Regulation after reform would react to outcomes rather than controlling the process of healthcare delivery.

The Impact of Diagnosis-Related Groups on the Cost of Hospitalization for End-Stage Renal Disease Patients at Rhode Island Hospital From 1987 to 1990

The introduction of diagnosis-related groups (DRGs) for the reimbursement of hospital costs in the Medicare population made no provisions to identify end-stage renal disease (ESRD) patients. To assess the impact of the DRGs on ESRD patients, we prospectively evaluated all hospitalizations (901) at the Rhode Island Hospital from July 1987 through April 1990 among a chronic hemodialysis population of 587 patients. The compiled data on length of hospital stay, cost per day, and total cost were compared with the accepted allowances as defined by the DRG codes assigned to the admissions. The mean values and comparisons were length of stay, 10.2 ± 21 days (ESRD) versus 9.7 ± 3.6 days (DRGs), P = 0.44; cost per day, $1,240 ± $685 (ESRD) versus $671 ± $897 (DRGs), P = 0.0001; and total cost, $9,660 ± $17,170 (ESRD) versus $6,815 ± $8,872 (DRGs), P = 0.0001, a difference of $2,275 per admission. The increase in daily, and thus total, costs was primarily due to the use of supplies, medications, laboratory procedures, and transfusion services. It appears from our data that the DRGs do not adequately reflect the cost of caring for ESRD patients with the same DRGs as non-ESRD patients because of increased demand for anCillary services. If these observations are confirmed, a reevaluation of the DRG process as it relates to ESRD patients is warranted.

Assessing Clinical Instability at Discharge The Clinician's Responsibility

A great deal of attention has been given to what should be hospital policies when a patient is admitted to the hospital. Who should see the patient? At what time after admission? What should constitute an admission history and physical? Very little attention, however, has been paid to determining when it is safe to send a patient home from the hospital. In addition, precious few randomized trials have been performed that use clinical criteria to compare outcomes following discharge for those people who had the customary length of stay vs a medically correct length of stay. 1,2 A little over a year ago, we wrote a series of articles 3-10 about the impact of diagnosis related group (DRG)—based prospective payment on quality of care for Medicare patients hospitalized with one of five conditions: congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. Our data source was a

Impact of Diagnosis-Related Groups on the quality of postoperative care of patients with neck dissections : MB Flynn, TG O'Daniel, DG Barnes, et al. Am J Surg 1990; 160:356–359

Impact of Diagnosis-Related Groups on the quality of postoperative care of patients with neck dissections : MB Flynn, TG O'Daniel, DG Barnes, et al. Am J Surg 1990; 160:356–359

Impact of diagnosis-related groups on the quality of postoperative care of patients with neck dissections

Two hundred eighty patients underwent neck dissection over a 10-year period: 138 during the 5-year period before the institution of Diagnosis-Related Group (DRG) reimbursement and 142 during the 5 years after DRG regulations. A comparison of these two groups by site of tumor, stage of disease, histopathology, previous treatment, type of neck dissection, whether neck dissection was carried out alone or in combination with another procedure, presence of preexisting disease, postoperative complications, and mortality revealed no significant differences. A 35% reduction in the length of hospital stay from 16 to 10 days was identified in the post-DRG group with no detrimental effects on patient care. The variables found to have the greatest impact on length of hospital stay were the extent of operation and postoperative complications.

The Impact of Diagnosis-Related Groups on Patient Acuity, Quality of Care, and Length of Stay

The consequences of the implementation of diagnosis-related groups (DRGs) include increased patient acuity level, shortened length of stay, and decreased quality of nursing care. The findings of this study did not support the expected changes in patient acuity level or quality of nursing care. In this study, technological changes and organizational variables may have buffered the expected negative consequences of the implementation of DRGs in a group of cardiovascular surgery patients.

Ethical Perspectives on Prospective Payment

Ethical Perspectives on Prospective Payment Dramatically rising prices in Medicare program led Congress in 1983 to pass legislation that changed method of reimbursement for Medicare hospital charges from a cost-based retrospective system to a prospective payment system (PPS). Medicare's PPS now pays hospitals a preset price for services to its beneficiaries based on average costs of hospital care for patients in diagnosis-related groups (DRGs). Outliers provide a mechanism for enhanced payments for exceptioanlly costly cases and for those whose care requires more days in hospital. But there are restrictive caps on number of outliers that a hospital can claim and amount that will be added to normal DRG payment for patients who qualify. Other adjustments have been built into DRGs related to case mix, wages, teaching, disproportionate share of indigent patients and status as sole provider in a community. The main thrust, however, is to define a single payment schedule in advance of treatment. The Medicare PPS approach shifts financial risk of treating Medicare patients to hospitals and gives them an incentive to provide care more efficiently. At same time, Congress also mandated that all hospitals seeking Medicare reimbursement contract with a peer review organization (PRO). PROs are responsible for assuring that care provided to Medicare beneficiaries is medically necessary, consistent with professional standards, and provided efficiently and economically. They monitor Medicare admissions to hospitals, review DRG designations, and review outlier cases. PROs help to enforce Medicare's DRG system and to achieve congressional intent of containing program costs. Some Difficulties The introduction of PPS has effected important changes in provision of health care whose ethical implications are worthy of examination. But significant changes are occurring rapidly throughout American health care. Health care costs, though moderating, are still increasing beyond general rates of inflation. Competitive pressures and marketing have increased dramatically. Medical services have been unbundled and typical locus of care has shifted away from hospitals and doctors' offices to nursing homes, shopping malls, and patients' homes. The number of physicians is rising and solo practice has given way to health maintenance organizations, preferred provider schemes, and other new clinical and financial arrangements. The nursing profession is under new pressures. Corporations have become keenly interested in containing health care costs. And more and more Americans are without health insurance protection--some 35 to 37 million. Given this backdrop of large-scale systemic change, it is very difficult to isolate effects of Medicare's new measures. We also lack reliable data on many of issues raised by Medicare's PPS. One of most important issues, for example, is impact of DRGs on general quality of care. But there is no routine systemic collection and analysis of data--on mortality, morbidity, and consumer satisfaction--needed to make a secure evaluation.(1) Some modesty about ethical assessment of so large a social reality is also appropriate. Any appraisal of goodness or badness of DRGs is open to challenge: Good or bad compared to what--bankruptcy of Medicare program, more taxation, further privatization, socialized medicine? Such a definitive comparative evaluation of DRGs cannot be attempted here. Nevertheless, an ethical evaluation of changes wrought by Medicare PPS is important and timely. For Medicare is, in words of a recent statement by American Association of Retired Persons, the flagship of American health care system--where it leads others follow.(2) Concerns about impact of DRGs on operation of flagship will be offered from two ethical perspectives: utilitarian and contractarian. …

The Impact of DRGs on Health Care Workers and Their Clients

Translation of hospital systems into an equation of dollars and pathology by basing reimbursement on diagnosis related groups (DRGs) forces a reversal of professional priorities that places cost containment first, raising dilemmas of cutting care and inadequate community resources for providers and clients. The impact of cost containment systems on health care professionals, particularly on social workers and nurses, includes the benefits of better documentation on hospital charts and greater awareness of the use of equipment and supplies, as well as the drawbacks of reduced long-term services for low income groups and increased stress on social workers and nurses pressured to provide optimal care for patients in a shorter amount of time. As patients requiring high tech medical interventions and patients needing seven-day-per-week nursing care are discharged, the need will arise for nurses trained at a higher level than ever before to function in an outpatient setting.

Establishing a cancer caregivers program

Recent improvements in diagnostic techniques and treatment modalities have resulted in increasing numbers of cancer patients receiving therapies on an ambulatory basis. In addition, current health care economics and the impact of diagnosis-related groups (DRGs) have contributed to decreasing lengths of hospital stays. As a result, the responsibility of providing care for the patient with cancer at home often rests mainly with the family members. A review of the literature indicated that this responsibility contributes to stress for family caregivers because of their lack of knowledge in implementing the skills required in managing the day-to-day care of the patients. The purpose of this paper is to describe the methodological strategies used in developing a cancer caregivers program. The objectives of the program were to assist family caregivers in meeting the physical needs of the patient at home as well as to enable the family caregivers to care for themselves.

The Possible Impact of DRGs on Nutritional Status of Patients Having Surgery for Cancer of the Head and Neck

Our purpose was to determine if the introduction of prospective payment according to diagnosis related groups (DRGs) was associated with any adverse effect on the nutritional status of patients undergoing massive resections for head and neck cancer. The hypothesis was that malnourished patients, in particular those admitted since prospective payment was instituted, would be less well nourished at the time of surgery due to shortened preoperative stays, and, therefore, they would have more postoperative complications than malnourished patients admitted before DRGs. We compared 59 male patients with cancer of the head and neck admitted for massive resections before the introduction of DRGs with 61 similar patients admitted after the introduction of DRGs. These patients were classified as being either malnourished or well nourished. Nutritional status did not differ significantly at admission but was worse at surgery after the introduction of DRGs. In malnourished patients, complication scores were over two times higher after the introduction of DRGs. We conclude that malnourished patients have not fared as well since the prospective payment system was introduced and that other ways need to be devised so malnourished patients can be treated, such as adjusting DRG payments or providing preadmission nutritional support.

The impact of DRGs on clinical research centers. A multi-institutional study.

Clinical research may be threatened by prospective payment systems (PPS), such as diagnosis-related groups (DRGs), since research protocols frequently entail greater hospital costs than traditional patterns of care. Higher costs often result from new procedures or protocols that extend or supplement, rather than replace, existing services.1 These have been partially funded through fee-for-service payments, thus providing a hidden subsidy of clinical research.' Fixed reimbursement under PPSs may be established at levels just adequate to cover the costs of care for a typical patient and may be insufficient to cover additional costs incurred in treating patients participating in clinical trials. As a result, research programs may be at risk as hospitals seek to eliminate services that cannot be managed efficiently.2 This study evaluates whether a hypothetical PPS equivalent to Medicare's DRGbased system would cover hospital costs for patients in General Clinical Research Centers (GCRCs), a patient-oriented re-

The impact of DRGs on the cost and quality of health care in the United States

The Prospective Payment System (PPS) represents a fundamental change in the way the United States government reimburses hospitals for medical services covered under Medicare, a federal health care insurance program for the elderly and disabled. PPS replaced the retrospective cost-based system of payment for Medicare services with a prospective payment system. Under PPS, a predetermined, specific rate for each discharge dictates payment according to the diagnosis related group (DRG) in which the discharge is classified. The PPS was intended to create financial incentives that encourage hospitals to restrain the use of resources while providing high-quality inpatient care. Both objectives appear to have been met under PPS. Hospital utilization has declined, average length of stay has fallen, and the locus of care has shifted from the inpatient setting to less costly outpatient settings. The growth in inpatient hospital benefits has slowed and the impending insolvency of the Medicare trust fund has been forestalled. Studies have found no deterioration in the quality of care rendered to Medicare beneficiaries. Neither the mortality rate nor the rate of re-admission (presumably related to premature discharge) increased under PPS. Indeed, PPS appears the have enhanced the quality of inpatient care by discouraging unnecessary and potentially harmful procedures, and by encouraging the concentration of complex procedures in facilities in which the high frequency of these procedures promotes efficiency. Incentive-based reimbursement also appears to have contributed to the growth in alternative delivery systems, such as HMOs and PPOs, which contain costs by maintaining a high volume of a limited range of services. The success of the PPS/DRG system in controlling costs and promoting quality in this country suggests its application in other countries, either as a method of reimbursement or as a product line management tool.

DRG Payment for Long-term Ventilator Patients—Revisited

This article provides a follow-up to an evaluation originally presented in Chest of the financial impact of diagnosis related group (DRG) payment for long-term ventilator-dependent Medicare patients at Rush-Presbyterian-St. Luke's Medical Center. Since the results of our original study were presented, the Health Care Financing Administration (HCFA) has created two new DRGs for patients who have respiratory principal diagnoses to help recognize the resource intensiveness associated with mechanical ventilator support. The original 95 patients' payment, which was originally calculated to be $2.2 million below costs, was recalculated to be $1.9 million below costs, representing a 13 percent reduction in the loss. We conclude that although HCFA's recent remedial action is a step in the right direction, it provides little relief from the DRG system's financial bias against long-term ventilator-dependent patients, because the new ventilator DRGs encompass only a small segment of these patients. As an alternative approach, we recommend a single DRG for patients who, regardless of their principal diagnoses, experience chronic respiratory failure requiring a minimum of three days of continuous ventilator treatment.

Impact of Diagnosis-Related Groups' Prospective Payment on Utilization of Medical Intensive Care

We examined the financial impact of diagnosis-related groups (DRGs) payment for Medicare patients receiving medical intensive care and looked for any change in the type of patients admitted to the medical intensive care unit (MICU) after one year's experience with DRGs. During 1984, payment for 267 Medicare patients receiving medical intensive care at a large, multispecialty referral hospital was calculated to be $2.6 million below cost, representing an average loss per discharge of $9,794. For those who died (42 percent), the average payment per case was $11,418 below the average per discharge cost. In 1985, 241 Medicare patients treated in the MICU showed an average loss per discharge of $14,113, which rose to $20,271 for those who expired (39.4 percent). There was no significant difference in mortality between the two groups and in type of patients per DRG assignment (p = 0.56 and p = 0.88, respectively) by Chi-squared test. Despite the 1984 DRG experience, there was no change in admission practices or utilization of MICU beds during 1985. Appropriate management responses are needed from both the Federal government and the medical profession for better utilization of MICU resources.