Medicare Diagnosis-related Group Research Articles

Prospective Assessment of Social Determinants of Health and Length of Stay Among Emergency General Surgery and Trauma Patients.

Social determinants of health (SDOH) including insurance and substance use affect 50-90% of health outcomes, yet there remains no standard means to quantify or predict their impact. We prospectively evaluated the effects of SDOH on length of stay (LOS) and readmissions among emergency general surgery (EGS) and trauma patients. We compared these outcomes with Medicare Diagnosis Related Group (DRG) data to better quantify the impact of SDOH. Adult (≥18years old) EGS/trauma patients admitted July 7-28, 2020 at a Level 1 trauma center were prospectively enrolled. Primary outcomes were overall LOS, one-year readmissions, and excess LOS (eLOS), defined as days beyond DRG mean LOS. Assessment of SDOH among the 52 patients enrolled revealed that 5.8% of patients were homeless; 26.9% experienced substance abuse; 13.5% were uninsured on admission; and 7.7% on discharge. Mean LOS was 5 ± 4days; 1-year readmission rate 25.0%; eLOS mean 1.75 ± 2.4days. LOS was associated with substance use (OR 70.6 95% CI 11.7-160.4). eLOS was associated with substance use (OR 6.1, 95% CI 1.5-25.1) and public or no insurance (OR 26.0, 95% CI 4.9-138.1). No correlations were found between SDOH and readmission rates. EGS and trauma patients experience high rates of negative SDOH which affect clinical outcomes including LOS and readmissions. Medicare DRG determined eLOS is a fiscally relevant measure of the impact of SDOH and differs from LOS and readmissions. Further investigation is required to determine if eLOS can delineate the effects of other SDOH on admission outcomes for this patient population.

Financial Incentives to Reduce Hospital-Acquired Infections Under Alternative Payment Arrangements.

OBJECTIVEThe financial incentives for hospitals to improve care may be weaker if higher insurer payments for adverse conditions offset a portion of hospital costs. The purpose of this study was to simulate incentives for reducing hospital-acquired infections under various payment configurations by Medicare, Medicaid, and private payers.DESIGNMatched case-control study.SETTINGA large, urban hospital system with 1 community hospital and 2 tertiary-care hospitals.PATIENTSAll patients discharged in 2013 and 2014.METHODSUsing electronic hospital records, we identified hospital-acquired bloodstream infections (BSIs) and urinary tract infections (UTIs) with a validated algorithm. We assessed excess hospital costs, length of stay, and payments due to infection, and we compared them to those of uninfected patients matched by propensity for infection.RESULTSIn most scenarios, hospitals recovered only a portion of excess HAI costs through increased payments. Patients with UTIs incurred incremental costs of $6,238 (P<.01), while payments increased $1,901 (P<.05) at public diagnosis-related group (DRG) rates. For BSIs, incremental costs were $15,367 (P<.01), while payments increased $7,895 (P<.01). If private payers reimbursed a 200% markup over Medicare DRG rates, hospitals recovered 55% of costs from BSI and UTI among private-pay patients and 54% for BSI and 33% for UTI, respectively, across all patients. Under per-diem payment for private patients with no markup, hospitals recovered 71% of excess costs of BSI and 88% for UTI. At 150% markup and per-diem payments, hospitals profited.CONCLUSIONSHospital incentives for investing in patient safety vary by payer and payment configuration. Higher payments provide resources to improve patient safety, but current payment structures may also reduce the willingness of hospitals to invest in patient safety.Infect Control Hosp Epidemiol 2018;39:509-515.

Abstract 187: Temporal Trends in Sex and Age Disparities in Acute Ischemic Stroke Treatment and Outcomes in the United States From 2004 to 2014

Background: Data on trends in intravenous thrombolysis (tPA) and mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients are outdated. We aim to: (1) Evaluate current age and sex-specific trends in tPA and MT usage following AIS in the USA (2) Compare in-hospital mortality and moderate-to-severe disability between men and women following tPA and/or MT. Methods: A total of 4,579,246 admissions was identified with the diagnosis of AIS from 2004-2014 using the National Inpatient Sample (NIS). Patients receiving IV tPA and/or MT were identified using ICD-9 procedural codes and Medicare Diagnosis-related Group codes. Weights provided in the NIS were used to compute overall unadjusted weighted frequency of IV tPA and MT in subgroups characterized by age and sex. Multivariate models were used to evaluate trends in tPA and MT usage in both sexes and to assess their association with in-hospital mortality and moderate-to-severe disability. Results: Across the study period from 2004 to 2014, tPA use increased by &gt;300% in both men (1.8% to 8.0%) and women (1.3% to 7.7%) but by 2014 marked disparity still existed by age (figure 1). MT use also increased by &gt;300% from 2004-2014 in both sexes (males 0.1% to 2.1% versus females 0.1 to 1.8%) but proportion of younger patients (18-39 years) receiving MT was higher compared to other age groups in both men and women (figure 1). After multivariable adjustment, there is no significant difference in MT amongst either sex, but women were less likely to receive IV tPA (OR 0.92, 95%CI 0.90-0.94, p&lt;0.001). There is no sexual disparity in odds of in-hospital mortality following tPA and/or MT but odds of moderate-to-severe disability following tPA was higher in women compared to men (OR 1.19, 95%CI 1.13-1.26, p&lt;0.001). Conclusion: TPA and MT use has increased significantly in the USA over the last decade but disparities in tPA usage and outcome by age and sex still exist.

Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery.

OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.

371 How Do Case Type, Length of Stay, and Comorbidities Affect Medicare Diagnosis-Related Group Reimbursement for Minimally Invasive Surgery for Deformity?

371 How Do Case Type, Length of Stay, and Comorbidities Affect Medicare Diagnosis-Related Group Reimbursement for Minimally Invasive Surgery for Deformity?

Estimation of Potential Cost Savings Associated With Reduced Rates of Cardiovascular Hospitalization Among Atrial Fibrillation/Flutter Patients Treated With Dronedarone in the ATHENA Trial

The aim of this study was to estimate, from a US payer perspective, potential cost savings resulting from the reduction in cardiovascular (CV) hospitalizations obtained with dronedarone in the ATHENA (A Placebo-Controlled, Double-Blind, Parallel Arm Trial to Assess the Efficacy of Dronedarone 400 mg bid for the Prevention of Cardiovascular Hospitalization or Death from any Cause in PatiENts with Atrial Fibrillation/Atrial Flutter) trial. ATHENA randomized atrial fibrillation/flutter patients to dronedarone (n=2301) or placebo (n=2327) plus standard care. Dronedarone significantly reduced first CV hospitalization/all-cause mortality over 12-30 months of follow-up. CV hospitalization costs (2008 values) from a US cohort of ATHENA-like atrial fibrillation/flutter patients with Medicare supplemental insurance (n=10,200) and diagnosis-related group costs of adverse event-related hospitalizations were applied to hospitalizations occurring in ATHENA. The impact of cost variation was assessed using Monte Carlo simulation. In ATHENA, dronedarone reduced the overall CV hospitalization rate (vs. placebo) by 29% over the first 12 months (33.36 vs. 47.19 events per 100 patients) and by 25% over the full study (51.15 vs. 68.55 events per 100 patients). Adverse event-related hospitalization rates (dronedarone vs. placebo) were low (0.48 vs. 0.21 and 0.56 vs. 0.26 events per 100 patients over 12 months and the full study, respectively). Overall hospitalization cost savings were estimated at $1329 and $1763 per patient over 12 months and the full study, respectively. Cost savings were relatively stable [mean (95% confidence interval): $1330 ($994-$1676) for the first 12 months and $1763 ($1369-$2184) for the full study] over 10,000 cycles of random variation.

After the revolution: DRGs at age 30.

1 October 2013 marked 30 years since Medicare began paying hospitals by diagnosis-related group (DRG), arguably the most influential innovation in the history of health care financing. Initially developed as a tool for hospital management, DRGs became the basis of the inpatient prospective payment system that Medicare implemented in 1983. The strong incentives were revolutionary in their impact. Medicare spending growth slowed sharply, and, more remarkable, hospitals posted record profits. After the link between cost and payment was broken, hospitals moved quickly to cut costs. Nevertheless, a literature survey concluded that none of the worst fears about adverse effects on patients were realized. Diagnosis-related groups have also come to define "the product of a hospital" for purposes of benchmarking and risk adjustment. The acceptance of DRG algorithms owes much to their categorical approach, clinical focus, and transparency. The 2 most commonly used algorithms, Medicare DRGs and All Patient Refined (APR) DRGs, typically explain more than 40% of cost variance in inpatient stays, although with considerable range by care category. Because Medicare DRGs are unsuitable for obstetrics, pediatrics, and neonatology, some payers prefer APR DRGs. Diagnosis-related groups have proven to be a suitable basis for payment, as evidenced by widespread use. Common issues include mitigation of adverse incentives, appropriate payment for extremely costly stays, applicability to certain hospitals and care categories, and growing complexity. The DRG experience offers lessons about the effectiveness of financial incentives, the likelihood of adverse effects, the usefulness of case-mix measures, the risks of growing complexity, and the example that sensible policy need not be the domain of any one political party or other entity.

Hospital accreditation, reimbursement and case mix: links and insights for contractual systems

BackgroundResource consumption is a widely used proxy for severity of illness, and is often measured through a case-mix index (CMI) based on Diagnosis Related Groups (DRGs), which is commonly linked to payment. For countries that do not have DRGs it has been suggested to use CMIs derived from International Classification of Diseases (ICD). Our research objective was to use ICD-derived case-mix to evaluate whether or not the current accreditation-based hospital reimbursement system in Lebanon is appropriate.MethodsOur study population included medical admissions to 122 hospitals contracted with the Lebanese Ministry of Public Health (MoPH) between June 2011 and May 2012. Applying ICD-derived CMI on principal diagnosis cost (CMI-ICDC) using weighing similar to that used in Medicare DRG CMI, analyses were made by hospital accreditation, ownership and size. We examined two measures of 30-day re-admission rate. Further analysis was done to examine correlation between principal diagnosis CMI and surgical procedure cost CMI (CMI-CPTC), and three proxy measures on surgical complexity, case complexity and surgical proportion.ResultsHospitals belonging to the highest accreditation category had a higher CMI than others, but no difference was found in CMI among the three other categories. Private hospitals had a higher CMI than public hospitals, and those more than 100 beds had a higher CMI than smaller hospitals. Re-admissions rates were higher in accreditation category C hospitals than category D hospitals. CMI-ICDC was fairly correlated with CMI-CPTC, and somehow correlated with the proposed proxies.ConclusionsOur results indicate that the current link between accreditation and reimbursement rate is not appropriate, and leads to unfairness and inefficiency in the system. Some proxy measures are correlated with case-mix but are not good substitutes for it. Policy implications of our findings propose the necessity for changing the current reimbursement system by including case mix and outcome indicators in addition to accreditation in hospital contracting. Proxies developed may be used to detect miss-use and provider adverse behavior. Research using ICD-derived case mix is limited and our findings may be useful to inform similar initiatives and other limited-setting countries in the region.

The financial implications of endovascular aneurysm repair in the cost containment era

Endovascular aneurysm repair (EVAR) is associated with significant direct device costs. Such costs place EVAR at odds with efforts to constrain healthcare expenditures. This study examines the procedure-associated costs and operating margins associated with EVAR at a tertiary care academic medical center. All infrarenal EVARs performed from April 2011 to March 2012 were identified (n = 127). Among this cohort, 49 patients met standard commercial instruction for use guidelines, were treated using a single manufacturer device, and billed to Medicare diagnosis-related group (DRG) 238. Of these 49 patients, net technical operating margins (technical revenue minus technical cost) were calculated in conjunction with the hospital finance department. EVAR implant costs were determined for each procedure. DRG 238-associated costs and length of stay were benchmarked against other academic medical centers using University Health System Consortium 2012 data. Among the studied EVAR cohort (age 75, 82% male, mean length of stay, 1.7 days), mean technical costs totaled $31,672. Graft implants accounted for 52% of the allocated technical costs. Institutional overhead was 17% ($5495) of total technical costs. Net mean total technical EVAR-associated operating margins were -$4015 per procedure. Our institutional costs and length of stay, when benchmarked against comparable centers, remained in the lowest quartile nationally using University Health System Consortium costs for DRG 238. Stent graft price did not correlate with total EVAR market share. EVAR is currently associated with significant negative operating margins among Medicare beneficiaries. Currently, device costs account for over 50% of EVAR-associated technical costs and did not impact EVAR market share, reflecting an unawareness of cost differential among surgeons. These data indicate that EVAR must undergo dramatic care delivery redesign for this practice to remain sustainable.

Average length of stay in hospitals in the USA

In the pursuit of lower health care costs, measures of efficiency, such as length of stay (LOS) come under increased scrutiny. There is a general perception that the operation of a free market in the USA leads to higher efficiency. However, lower average LOS in US hospitals is shown to decrease in proportion to the number of beds per hospital. This is partly due to the role of hospital size and the truncating effect of Medicare diagnosis-related group (DRG) payments on costs and therefore upon average LOS. The USA should not be used as a so-called efficiency benchmark for LOS, and on a like-for-like basis seems to have an average LOS which is comparable to that in England.

Developing strategies for predicting and preventing readmissions in vascular surgery

The escalating cost burden of hospital readmission has prompted recent nationwide efforts aimed at reducing the incidence of this important quality measure. Because patients undergoing vascular surgery account for a significant proportion of readmissions, vascular surgeons may face reduced reimbursements in the near future if these trends continue. However, risk factors associated with readmission remain poorly defined, and further research is needed to identify interventions that will prevent readmission following vascular procedures. Accordingly, this manuscript will (1) propose a conceptual model to explain the driving forces behind readmissions in vascular surgery, (2) review current evidence directed at identifying risk factors and evaluating interventions to reduce readmissions across different medical and surgical specialties, and (3) identify key areas in patient care where targeted research or interventions may be implemented in vascular surgery.

Use of Bone Morphogenetic Proteins in Spinal Fusion Surgery for Older Adults With Lumbar Stenosis

Retrospective cohort study of Medicare claims. Examine trends and patterns in the use of bone morphogenetic proteins (BMP) in surgery for lumbar stenosis; compare complications, reoperation rates, and charges for patients undergoing lumbar fusion with and without BMP. Small, randomized trials have demonstrated higher rates of solid fusion with BMP than with allograft bone alone, with few complications and, in some studies, reduced rates of revision surgery. However, complication and reoperation rates from large population-based cohorts in routine care are unavailable. We identified patients with a primary diagnosis of lumbar stenosis who had fusion surgery in 2003 or 2004 (n = 16,822). We identified factors associated with BMP use: major medical complications during the index hospitalization, rates of rehospitalization within 30 days, and rates of reoperation within 4 years of follow-up (through 2008). Use of BMP increased rapidly, from 5.5% of fusion cases in 2003 to 28.1% of fusion cases in 2008. BMP use was greater among patients with previous surgery and among those having complex fusion procedures (combined anterior and posterior approach, or greater than 2 disc levels). Major medical complications, wound complications, and 30-day rehospitalization rates were nearly identical with or without BMP. Reoperation rates were also very similar, even after stratifying by previous surgery or surgical complexity, and after adjusting for demographic and clinical features. On average, adjusted hospital charges for operations involving BMP were about $15,000 more than hospital charges for fusions without BMP, though reimbursement under Medicare's Diagnosis-Related Group system averaged only about $850 more. Significantly fewer patients receiving BMP were discharged to a skilled nursing facility (15.9% vs. 19.0%, P < 0.001). In this older population having fusion surgery for lumbar stenosis, uptake of BMP was rapid, and greatest among patients with prior surgery or having complex fusion procedures. BMP appeared safe in the perioperative period, with no increase in major medical complications. Use of BMP was associated with greater hospital charges but fewer nursing home discharges, and was not associated with reduced likelihood of reoperation.

Failure to Rescue Measure

The inclusion of the failure to rescue (FTR) measure as one of the Centers for Medicare and Medicaid Services Inpatient Prospective Payment System measures has raised questions about the characteristics of FTR cases and their outcomes. In this study, we validated 75% of the identified FTR complications using medical record review (n = 461). Nearly half (49.5%) of the complications originated in the community and were present on admission. Acute renal failure, gastrointestinal hemorrhage, and sepsis most often originated in the community. Cardiac arrest/shock, pneumonia, and pulmonary embolism and deep vein thrombosis most often developed in the hospitals. These findings have important implications for practice as clinical leadership focuses on the prevention and aggressive management of complications to prevent death, increased length of stay, and possible reductions in Medicare diagnosis related groups' reimbursements.

Changes in Medicare diagnosis related group (DRG) system for primary and revision hip and knee replacements and their implications on hospital reimbursement

Changes in Medicare diagnosis related group (DRG) system for primary and revision hip and knee replacements and their implications on hospital reimbursement

Palliative Care in the Treatment of Advanced Heart Failure

Heart failure is epidemic in developed countries and is expanding rapidly worldwide. Roughly 5% of patients with heart failure have end-stage disease that is refractory to medical therapy (stage D heart failure).1 Palliative care consultation relieves symptoms, improves patient satisfaction, and decreases the costs of care for these patients. Despite this, only a small fraction of end-stage heart failure patients receive palliative care consultation. In recognition of this, palliative/hospice care referral was recommended for end-stage heart failure (Level of Evidence 1A) in the most recent American College of Cardiology/American Heart Association heart failure guidelines.2 To identify evidence-based studies of palliative care in heart failure, we searched the Medline database for literature with the medical subject headings “heart failure” and “palliative care,” “supportive care,” or “symptom management” and found 394 results. We identified 92 systematic reviews, 44 of which were English-language systematic reviews published within the past 5 years. More than 5 million Americans have heart failure, with a yearly incidence estimated to be >500 000.3 The number of deaths due to heart failure in 2004 was 284 365, which exceeds the deaths due to lung cancer, breast cancer, prostate cancer, and HIV/AIDS combined (Table 1).3–5 Even as the national death rate decreased by 2% from 1994 to 2004, deaths due to heart failure increased by 28%. View this table: Table 1. Incidence of and Number of Deaths Due to Heart Failure Compared With Other Common Causes of Death in the United States The yearly cost of heart failure was roughly $30 billion in 2006.6 The mean hospital length of stay is almost 6 days, and more than one third of patients are admitted for more than 5 days. Nearly half of the hospitalizations for heart failure exceed Medicare diagnosis-related groups reimbursement.7 Compared with all other patients, …

2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults

published online Mar 26, 2009; J. Am. Coll. Cardiol. Lynne Warner Stevenson, and Clyde W. Yancy Ganiats, Marvin A. Konstam, Donna M. Mancini, Peter S. Rahko, Marc A. Silver, Abraham, Donald E. Casey, Arthur M. Feldman, Gary S. Francis, Theodore G. Silver, Lynne Warner Stevenson, Clyde W. Yancy, Mariell Jessup, William T. Konstam, Donna M. Mancini, Keith Michl, John A. Oates, Peter S. Rahko, Marc A. M. Feldman, Gary S. Francis, Theodore G. Ganiats, Mariell Jessup, Marvin A. Transplantation, Sharon Ann Hunt, William T. Abraham, Marshall H. Chin, Arthur Force on Practice Guidelines, International Society for Heart and Lung American College of Cardiology Foundation/American Heart Association Task Diagnosis and Management of Heart Failure in Adults 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the This information is current as of March 27, 2009 http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.11.013v1 located on the World Wide Web at: The online version of this article, along with updated information and services, is

The Changing Culture in Modern Medicine: A Psychiatrist's Perspective

Cultural competence advances global healthcare by promoting greater understanding of individual patients, combined interventions, and maximum adherence. However, the healthcare professional's culture and the culture of medicine itself must also be considered. In westernized medicine, especially America, improved technology and therapeutics profoundly impact medical culture; but medical economics is as significant. Managed care and Medicare Diagnosis-Related Groups (DRGs) strongly affect American medical economics with resultant decreased physicians' incomes, increased patient volumes, decreased time spent with each patient, and decreased subjective/objective quality of care. Physicians' roles blur with duties delegated to lesser qualified healthcare professionals to maximize patients seen and generated incomes. In psychiatry, performing multiple psychopharmacology visits hourly is economically more productive than an hour therapy session. Doctors need to understand that in entering medicine they enter life's career of nobility in which they serve others, do not expect to become wealthy, but at life's end are able to state a job well done with caring for all. Perhaps then, less harm will be done to patients in doctors' haste to earn more money by seeing too many patients too briefly.

The changing culture in modern medicine: A psychiatrist's perspective

Cultural competence advances global healthcare by promoting greater understanding of individual patients, combined interventions, and maximum adherence. However, the healthcare professional's culture and the culture of medicine itself must also be considered. In westernized medicine, especially America, improved technology and therapeutics profoundly impact medical culture; but medical economics is as significant. Managed care and Medicare Diagnosis-Related Groups (DRGs) strongly affect American medical economics with resultant decreased physicians' incomes, increased patient volumes, decreased time spent with each patient, and decreased subjective/objective quality of care. Physicians' roles blur with duties delegated to lesser qualified healthcare professionals to maximize patients seen and generated incomes. In psychiatry, performing multiple psychopharmacology visits hourly is economically more productive than an hour therapy session. Doctors need to understand that in entering medicine they enter life's career of nobility in which they serve others, do not expect to become wealthy, but at life's end are able to state a job well done with caring for all. Perhaps then, less harm will be done to patients in doctors' haste to earn more money by seeing too many patients too briefly.

Feasibility and validity of International Classification of Diseases based case mix indices

BackgroundSeverity of illness is an omnipresent confounder in health services research. Resource consumption can be applied as a proxy of severity. The most commonly cited hospital resource consumption measure is the case mix index (CMI) and the best-known illustration of the CMI is the Diagnosis Related Group (DRG) CMI used by Medicare in the U.S. For countries that do not have DRG type CMIs, the adjustment for severity has been troublesome for either reimbursement or research purposes. The research objective of this study is to ascertain the construct validity of CMIs derived from International Classification of Diseases (ICD) in comparison with DRG CMI.MethodsThe study population included 551 acute care hospitals in Taiwan and 2,462,006 inpatient reimbursement claims. The 18th version of GROUPER, the Medicare DRG classification software, was applied to Taiwan's 1998 National Health Insurance (NHI) inpatient claim data to derive the Medicare DRG CMI. The same weighting principles were then applied to determine the ICD principal diagnoses and procedures based costliness and length of stay (LOS) CMIs. Further analyses were conducted based on stratifications according to teaching status, accreditation levels, and ownership categories.ResultsThe best ICD-based substitute for the DRG costliness CMI (DRGCMI) is the ICD principal diagnosis costliness CMI (ICDCMI-DC) in general and in most categories with Spearman's correlation coefficients ranging from 0.938-0.462. The highest correlation appeared in the non-profit sector. ICD procedure costliness CMI (ICDCMI-PC) outperformed ICDCMI-DC only at the medical center level, which consists of tertiary care hospitals and is more procedure intensive.ConclusionThe results of our study indicate that an ICD-based CMI can quite fairly approximate the DRGCMI, especially ICDCMI-DC. Therefore, substituting ICDs for DRGs in computing the CMI ought to be feasible and valid in countries that have not implemented DRGs.

Optimal Medical Therapy for Heart Failure

Heart failure (HF) remains a major cardiovascular health problem, afflicting millions of people worldwide. Nearly 5 million patients in the United States have HF, and nearly 500000 patients are initially diagnosed with HF every year. Framingham databases estimate that a person has 1 in 5 chances of developing HF in their lifetime. The incidence of HF more than doubles with each decade after the age of 45 years, and approximately 35% of all new HF diagnosis result in hospitalization in the subsequent 12 months. The disorder is the underlying reason for 12 to 15 million office visits and 6.5 million hospital days each year. During the last 10 years, the annual number of hospitalizations has increased from approximately 550000 to nearly 900000 for HF as a primary diagnosis and from 1.7 to 2.6 million for HF as a primary or secondary diagnosis. Heart failure is primarily a disease of the elderly. Approximately 6% to 10% of people older than 65 years have HF, and approximately 80% of patients hospitalized with HF are older than 65 years. Heart failure is the most common Medicare diagnosis-related group, and more Medicare dollars are spent for the diagnosis and treatment of HF than for any other diagnosis. Heart failure is a syndrome that can be caused by a variety of conditions that result in damage to the myocardium. Coronary artery disease is the single most common cause of HF, with a significant increase in the number of patients who can be identified, from 29% to 40%, when coronary angiography is systematically used in addition to clinical criteria. In a minority of patients, isolated hypertension is regarded as the primary cause of HF; however, it frequently coexists with coronary artery disease. However,