Increase In Case Mix Index Research Articles

Implementation of a Real-Time Documentation Assistance Tool: Automated Diagnosis (AutoDx).

Clinical documentation improvement programs are utilized by most health care systems to enhance provider documentation. Suggestions are sent to providers in a variety of ways, and are commonly referred to as coding queries. Responding to these coding queries can require significant provider time and do not often align with workflows. To enhance provider documentation in a more consistent manner without creating undue burden, alternative strategies are required. The aim of this study is to evaluate the impact of a real-time documentation assistance tool, named AutoDx, on the volume of coding queries and encounter-level outcome metrics, including case-mix index (CMI). The AutoDx tool was developed utilizing tools existing within the electronic health record, and is based on the generation of messages when clinical conditions are met. These messages appear within provider notes and required little to no interaction. Initial diagnoses included in the tool were electrolyte deficiencies, obesity, and malnutrition. The tool was piloted in a cohort of Hospital Medicine providers, then expanded to the Neuro Intensive Care Unit (NICU), with addition diagnoses being added. The initial Hospital Medicine implementation evaluation included 590 encounters pre- and 531 post-implementation. The volume of coding queries decreased 57% (p < 0.0001) for the targeted diagnoses compared with 6% (p = 0.77) in other high-volume diagnoses. In the NICU cohort, 829 encounters pre-implementation were compared with 680 post. The proportion of AutoDx coding queries compared with all other coding queries decreased from 54.9 to 37.1% (p < 0.0001). During the same period, CMI demonstrated a significant increase post-implementation (4.00 vs. 4.55, p = 0.02). The real-time documentation assistance tool led to a significant decrease in coding queries for targeted diagnoses in two unique provider cohorts. This improvement was also associated with a significant increase in CMI during the implementation time period.

Major Drivers of Increased Cost of Inpatient Stroke Care in the Wake of the COVID-19 Pandemic (P3-7.001)

<h3>Objective:</h3> To evaluate the impact of the COVID-19 pandemic on inpatient stroke care costs in a 23 hospital, integrated University Hospitals System Stroke Program (UHSSP). <h3>Background:</h3> Since 2008, the UHSSP implemented system-wide clinical practice guidelines and analytics to optimize high-value stroke care by improving quality and reducing unnecessary costs of care. <h3>Design/Methods:</h3> All stroke hospital discharges for DRGs 64–66 at 12 UHSSP hospitals were analyzed for volume, case mix index (CMI), inpatient total direct costs (TDC) including length of stay (LOS), ICU LOS, diagnostics, imaging, lab, OR, Pharmacy, supply and direct contribution margin (DCM) using EPSi™ and quality using <i>GWTG-</i>Stroke® and STATIT piMD™. The data encompassed three waves: 2017 (baseline), 2019 (2 years into a high-reliability initiative), and through 2q2022 (2 years into the pandemic). <h3>Results:</h3> For all medically managed stroke at the academic hub, the average TDC, CMI and positive DCM all increased (by +15%, +0.07, and +0.5% respectively) in 2019 over baseline in 2017. However, in 2q2002 over 2019, there was a significant increase in TDC, not scaled to the increase in CMI, and associated with a significant reduction in the positive DCM (by +63%, +0.06, and −61% respectively). The increased costs were driven by increased ICU LOS (ratio of ICU LOS vs non-ICU LOS +37%, from 2.05 to 2.8-fold) associated with nursing shortages and shifting step-down care to the ICU, and anticoagulant reversal agents accounting for a growth of 37% to 56% of all pharmacy costs. The same pattern was seen analyzing all hospitals in aggregate. <h3>Conclusions:</h3> The inpatient stroke costs have increased significantly since the pandemic, resulting in many health systems now operating in a deficit. Analyses have focused on pharmacy, labor and supply costs. This report identifies an unanticipated significant cost related to prolonged ICU LOS resulting from nursing staffing shortages. <b>Disclosure:</b> The institution of Dr. Sila has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Syntactx . Dr. Sila has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech . Dr. Sila has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Astrazeneca . Colin Beilman has nothing to disclose. Mr. Vincent has nothing to disclose. Dr. De Georgia has nothing to disclose. Dr. Sarraj has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for AstraZeneca. Dr. Sarraj has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Stryker Neurovascular. Dr. Sarraj has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Stryker Neurovascular. The institution of Dr. Sarraj has received research support from Stryker Neurovascular.

The association between operating margin and surgical diversity at Critical Access Hospitals.

Surgical volume is correlated with increased hospital profitability, yet many Critical Access Hospitals (CAHs) offer few or no inpatient surgical services. This study aims to investigate the impact of the presence of different inpatient surgical services on CAH profitability. The study design was a cross-sectional analysis of financial data from the most recent fiscal year (FY) of 1299 CAHs. Multiple linear regression was utilized to assess how the operating margin was affected by the number of different inpatient surgical services offered per hospital. Covariates known to be associated with hospital profitability included occupancy rate, case mix index (CMI), system affiliation, ownership status (public, private, or nonprofit), and geographic region. The regression model for the CAH operating margin returned an R2 value of 0.18. Each additional inpatient surgical service corresponded to a 1.5% increase in operating margin (p=0.0413). Each 10% increase in occupancy rate and 0.1 increase in CMI corresponded to a 0.9% increase in operating margin (p=0.0032 and p=0.0176, respectively). The number of surgical services offered per CAH showed positive correlations with occupancy rate (r=0.23, p<0.0001) and CMI (r=0.59, p<0.0001). A positive correlation exists between operating margin and the diversity of inpatient surgical specialties available at CAHs. Furthermore, providing surgery allows CAHs to accommodate higher occupancy rates and case mixes, both of which are significantly and positively correlated with CAH operating margin.

PSU25 THE CHANGE OF CASE MIX INDEX IN THE PUBLICLY FINANCED HUNGARIAN ONE-DAY SURGERY CARE

In the past decade, the progression of one-day surgery was significant in Hungary, because there were few important initiations in the Hungarian health policy which were able to facilitate the spreading of one-day surgery from the beginning of 2010s’. The aim of the study is to evaluate the changes of Case Mix Index (CMI) within the Diagnosis Related Groups (DRG) system in publicly financed Hungarian one-day surgery care between 2008-2018. Data were provided from the financial database of the National Health Insurance Fund Administration of Hungary. The database of the research consisted all publicly financed one-day surgery case and DRG cost weight numbers related to the type, name and financing code of health care institutes between 2008-2018. During the examined period, 2,322,879 public financed one-day surgery cases, and 1,241,708 DRG cost weight numbers were reimbursed by the National Health Insurance Fund Administration of Hungary. The number of cases increased 275%, meanwhile the DRG cost weight numbers increased 370% between 2008-2018. Nationally, the mean CMI was 0.52307 (SD=0.4428- 0.6032) between 2008-2018. It was the highest in 2018 (CMI=0.5989) and the lowest in 2008. (CMI=0.4409). The changes of CMI from the viewpoint of the type of health care institutes were rather different. The CMI of universities (0.6388), county hospitals (0.5232), national institutes (0.5977), and specialized hospitals (0.5989) were above the national average (0.5346). According to our results, the type of health care institute influenced the value of CMI (p=0.001). The changes of CMI among universities were rather different. We could verify that the constant increase in the utilization of one-day surgery did not affect the increase in CMI on the national level, but the type of the health care institute influenced the value of CMI.

Effects of the new injury type catalogue of the German statutory accident insurance on a center for severe injury type procedures

Aretrospective study of all inpatients treated in the context of the DAV, VAV and SAV procedures at a SAV center from the 2nd and 3rd quarters of 2018 was carried out. The development of the number of cases, the case mix index (CMI), the mean number of operations, the mean time in the operating room and the length of hospitalization were analyzed. Furthermore, an assessment of the SAV cases was carried out with respect to the new developments and with particularly reference to complications. The total number of inpatients in the context of the DAV, VAV, SAV procedures changed only slightly. There was aclear decrease in DAV cases and arelevant increase in SAV cases. The CMI increased by 47%, the number of surgical procedures by 15%, the mean time in the operating room by 36% and the length of hospitalization by 43%. When converted to a daily operating room unit of 7 h (Tagestischeinheit, TTE) the operating room time increased from 89 to 108 TTE and the length of hospitalization increased from 1028 to 1358 days. Of the 111 SAV cases in the 3rd quarter, 52% were assigned to the catalogue number11 "complications". In comparison to the previous version of the VAV/SAV catalogue, it was now possible to assign all inpatients to asingle category. The modifications of the VAV in the observational period led to an enormous increase in SAV cases. It remains to be seen whether this development is confirmed in subsequent quarters. The increase in CMI, the number of necessary operations, operating room times and duration of hospitalization showed the necessity of these innovations on structural changes of hospitals involved in the treatment of SAV cases.

Does Surgical Volume and Complexity Affect Cost and Mortality in Otolaryngology-Head and Neck Surgery?

(1) To evaluate whether admission volume and case complexity are associated with mortality rates and (2) evaluate whether admission volume and case complexity are associated with cost per admission. Retrospective case series. Tertiary academic hospital. The Vizient database was queried for inpatient admissions between July 2015 and March 2017 to an otolaryngology-head and neck surgery service. Data collected included admission volume, length of stay, intensive care unit (ICU) status, complication rates, case mix index (CMI), and cost data. Regression analysis was performed to evaluate the relationship between cost, CMI, admission volume, and mortality rate. In total, 338 hospitals provided data for analysis. Mean hospital admission volume was 182 (range, 1-1284), and mean CMI was 1.69 (range, 0.66-6.0). A 1-point increase in hospital average CMI was associated with a 40% increase in odds for high mortality. Admission volume was associated with lower mortality, with 1% lower odds for each additional case. A 1-point increase in CMI produces a $4624 higher total cost per case (95% confidence interval, $4550-$4700), and for each additional case, total cost per case increased by $6. For otolaryngology inpatient services at US academic medical centers, increasing admission volume is associated with decreased mortality rates, even after controlling for CMI and complication rates. Increasing CMI levels have an anticipated correlation with higher total costs per case, but admission volume is unexpectedly associated with a significant increase in average cost per case.

Impact of a care delivery redesign initiative for vascular surgery

ObjectiveA hospital-wide quality improvement process through a care delivery redesign (CDR) was initiated to improve patient care efficiency, clinical documentation, and length of stay (LOS). The impact of CDR was assessed through LOS, unplanned readmission rates, and hospital financial metrics. MethodsThe CDR team consisted of the Chief of Vascular Surgery, inpatient nurse practitioner, dedicated case manager, clinical documentation improvement specialist, and vascular surgery residents and faculty. The nurse practitioner facilitated patient care coordination, resident system-based education, and multidisciplinary collaboration. Tools created to track performance and to ensure sustainability included daily discussions of patient care barriers and solutions; standardized order sets; a mobile app for residents containing resident service expectations, disease-specific resources, and vascular surgery journal links; and a weekly inpatient tracker showing real-time patient care data. Outcome measures included LOS, case mix index, contribution margin, and unplanned readmissions. Each outcome was determined for all inpatient admissions the year before and the 12 months after CDR was initiated. Outcomes were compared between the two groups. ResultsImplementation of CDR resulted in a 23% decrease in LOS (P = .003), reducing the gap to the Centers for Medicare and Medicaid Services geometric mean LOS from 2.1 days to 0.5 day (P < .001). Clinical documentation resulted in an increase in case mix index of 10% (P = .011). The 30-day unplanned readmission rates did not change in the 12 months after CDR was initiated compared with the year before (P = .92). Financial data demonstrated decreased variable cost and increased revenue resulting in a $1.89 million increase in contribution margin. ConclusionsA CDR predicated on a dedicated service line advanced practitioner, clinical documentation education, weekly service tracker review, and real-time management of system-related barriers to patient care is described. Implementation of the CDR reduced hospital LOS with no change in unplanned readmissions and provided significant financial benefit to the hospital by increasing revenue and decreasing variable cost.

SS10. Financial Impact of Implementing Care Delivery Redesign Initiatives for Vascular Surgery in a Hospital Setting

A fragmented health care system contributes to suboptimal resource utilization and care coordination. A Care Delivery Redesign (CDR) for the vascular surgery service was developed to improve diagnosis-related group (DRG) assignment, to decrease length of stay (LOS), and to minimize care variation through standardized care pathways. We measured the value of CDR through hospital financial metrics. The CDR consisted of a physician champion, inpatient nurse practitioner, and dedicated case manager. The vascular surgery nurse practitioner played a central role in CDR by facilitating all aspects of patient care coordination, resident education, and communication with hospital coding specialists. A real-time weekly inpatient tracker was created and reviewed weekly during vascular conference. The tracker contains patient identifier, admission and discharge date, attending, admission and discharge unit, current LOS, Centers for Medicare and Medicaid Services geometric mean LOS, and corresponding DRG. Tools created to track performance and to ensure sustainability included daily discussions of barriers and solutions on patient rounds, creation of a vascular surgery mobile app for residents, and a patient avoidable delay tracker. End points included LOS, total variable cost, case mix index, and vascular surgery contribution margin compared with pre-CDR contribution margin. Implementation of CDR resulted in a 23% decrease in LOS, reducing the gap to Centers for Medicare and Medicaid Services geometric mean LOS by 1.6 days, from 2.2 days to 0.5 day. Improvement and changes in documentation captured accurate DRGs, which resulted in an increase in case mix index of 21%. This resulted in contribution margin amounting to $1.88 million. The CDR structure as described reduces hospital LOS and improves financial service metrics. The structure is predicated on a dedicated service line advanced practitioner, weekly service tracker review, and real-time management of barriers and solutions to system-related issues. As designed, CDR provided significant financial benefit to the hospital while facilitating patient care.

Trends in Resource Utilization Associated with the Inpatient Treatment of Neonatal Congenital Heart Disease

While neonates account for a significant proportion of health care expenditures related to inpatient care for congenital heart disease, key drivers of resource utilization among this population are poorly defined. Data from 2005 through 2011 were extracted from the Pediatric Health Information System for patients assigned a discharge All Patient Refined Diagnosis Related Group of 630 (neonates with birthweight >2499 g undergoing a major cardiovascular procedure). Mortality risk adjustment for patients undergoing operative interventions was performed with the Risk Adjusment in Congenital Heart Surgery (RACHS-1) score. A total of 13 156 cases were included in the analysis. Despite only a 3% increase in case mix index and no significant change in operative acuity over the study period (RACHS classifications of 3 or greater 67% in 2005 vs. 66% in 2011, P = .64), there were inflation-adjusted increases in both total estimated cost per case of (50% to $151 760 in 2011, P < .001), and mean charge per case (33% to $433 875 in 2011, P < .001). Pharmacy charges increased by 16% (P < .001), with agents including chlorothiazide and albumin accounting for the highest patient charges over the study period. Imaging charges increased by 42% (P < .001), with an average of 5.7 echocardiograms and $6517 in associated charges per case by 2011. While the proportion of patients receiving nitric oxide remained consistent, mean duration of administration increased by 25% to 6.6 days by 2011, accounting for average charges of $52 141 per patient exposed. Among neonates with serious congenital heart disease, increases in both institutional costs and charges to the patient are associated with relatively consistent utilization practices in recent years. Multiinstitutional collaboration may prove useful in aligning evidence-based reductions in practice variation with limitations in resource utilization without compromising the quality of care.

Changing Patient Classification System for Hospital Reimbursement in Romania

To evaluate the effects of the change in the diagnosis-related group (DRG) system on patient morbidity and hospital financial performance in the Romanian public health care system. Three variables were assessed before and after the classification switch in July 2007: clinical outcomes, the case mix index, and hospital budgets, using the database of the National School of Public Health and Health Services Management, which contains data regularly received from hospitals reimbursed through the Romanian DRG scheme (291 in 2009). The lack of a Romanian system for the calculation of cost-weights imposed the necessity to use an imported system, which was criticized by some clinicians for not accurately reflecting resource consumption in Romanian hospitals. The new DRG classification system allowed a more accurate clinical classification. However, it also exposed a lack of physicians' knowledge on diagnosing and coding procedures, which led to incorrect coding. Consequently, the reported hospital morbidity changed after the DRG switch, reflecting an increase in the national case-mix index of 25% in 2009 (compared with 2007). Since hospitals received the same reimbursement over the first two years after the classification switch, the new DRG system led them sometimes to change patients' diagnoses in order to receive more funding. Lack of oversight of hospital coding and reporting to the national reimbursement scheme allowed the increase in the case-mix index. The complexity of the new classification system requires more resources (human and financial), better monitoring and evaluation, and improved legislation in order to achieve better hospital resource allocation and more efficient patient care.