Use Of Diagnosis-related Groups Research Articles

Posterior Cervical Fusion for Fracture Is Not the Same as Fusion for Degenerative Cervical Spine Disease: Implications for a Bundled Payment Model.

Retrospective. To understand differences in 30-day outcomes between patients undergoing posterior cervical fusion (PCF) for fracture versus degenerative cervical spine disease. Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement revolve around the use of diagnosis-related groups to categorize patients for reimbursement purposes. Though a PCF performed for a fracture may have a different postoperative course of care as compared with a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate payments based on the indication/cause of surgery. The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program was queried using Current Procedural Terminology code 22600 to identify patients receiving elective PCFs. Multivariate analyses were used to compare rates of 30-day severe adverse events, minor adverse events, readmissions, length of stay, and nonhome discharges between the 2 groups. A total 2546 (91.4%) PCFs were performed for degenerative cervical spine pathology and 240 (8.6%) for fracture. After adjustment for differences in baseline clinical characteristics, patients undergoing a PCF for a fracture versus degenerative pathology had higher odds of severe adverse events [18.8% vs. 10.6%, odds ratio (OR): 1.65 (95% CI, 1.10-2.46); P =0.015], prolonged length of stay >3 days [54.2% vs. 40.5%, OR: 1.93 (95% CI, 1.44-2.59); P <0.001], and nonhome discharges [34.2% vs. 27.6%, OR: 1.54 (95% CI, 1.10-2.17); P =0.012]. Patients undergoing PCFs for fracture have significant higher rates of postoperative adverse events and greater resource utilization as compared with individuals undergoing elective PCF for degenerative spine pathology. The study calls into question the need of risk adjustment of bundled prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients.

Implementation of diagnosis related groups in a high-complexity health institution in Colombia

One of the greatest challenges for health care institutions is to know the hospital product (HP), defined as patients, diagnoses and resources used in health care. Proper measurement of HP allows an effective resource management. The Diagnosis Related Groups (DRG) system facilitates the measurement of HP, classifying patients according to their characteristics, complexity, and resource consumption. To describe the implementation of DRGs in a high complexity health care institution in Colombia and to describe the incidence of coding errors. A random sample of 98 episodes was selected out of 3802 episodes registered from June to September 2019. We described the cumulative incidence of errors in the assignment of main diagnoses, procedures and the variable "Present on admission" (POA). An incorrect assignment of the main diagnosis was found in 18/98 episodes (18%, 95% confidence intervals (CI)11-27). Seventeen of 98(17%-95% CI10.4-26) and 8/98(8%-95% CI 3.6-15) had incorrect assignment of POA ("NO" or "YES" respectively). Eighteen episodes had at least one procedure incorrectly assigned (19% - 95%CI (11.4 - 28.5)). The use of DRGs improves hospital efficiency. Its implementation is possible in health care institutions in Colombia. However, the commitment of the institution's clinical and administrative staff is essential.

Evaluation of Length of Stay, Care Volume, In-Hospital Mortality, and Emergency Readmission Rate Associated With Use of Diagnosis-Related Groups for Internal Resource Allocation in Public Hospitals in Hong Kong

Hong Kong's internal resource allocation system for public inpatient care changed from a global budget system to one based on diagnosis-related groups (DRGs) in 2009 and returned to a global budget system in 2012. Changes in patient and hospital outcomes associated with moving from a DRG-based system to a global budget system for inpatient care have rarely been evaluated. To examine associations between the introduction and discontinuation of DRGs and changes in length of stay, volume of care, in-hospital mortality rates, and emergency readmission rates in the inpatient population in acute care hospitals overall, stratified by age group, and across 5 medical conditions. This cross-sectional study included data from patients aged 45 years or older who were hospitalized in public acute care settings in Hong Kong before the introduction (April 2006 to March 2009), during implementation (April 2009 to March 2012), and after discontinuation (April 2012 to November 2014) of the DRG scheme. Data analysis was conducted from January to June 2021. Public hospitals transitioned from a global budget payment system to a DRG-based system in April 2009 and returned to a global budget system in April 2014. The main outcome was the association of use of DRGs with patient-level length of stay, in-hospital mortality rate, 1-month emergency readmission rate, and population-level number of admissions per month. An interrupted time series design was used to estimate changes in the level and slope of outcome variables after introduction and discontinuation of DRGs, accounting for pretrends. This study included 7 604 390 patient episodes. Overall, the mean (SD) age of patients was 68.97 (13.20) years, and 52.17% were male. The introduction of DRGs was associated with a 1.77% (95% CI, 1.23%-2.32%) decrease in the mean length of stay, a 2.90% (95% CI, 2.52%-3.28%) increase in the number of patients admitted, a 4.12% (95% CI, 1.89%-6.35%) reduction in in-hospital mortality, and a 2.37% (95% CI, 1.28%-3.46%) decrease in emergency readmissions. Discontinuation of the DRG scheme was associated with a 0.93% (95% CI, 0.42%-1.44%) increase in the mean length of stay and a 1.82% (95% CI, 1.47%-2.17%) reduction in the number of patients treated after adjusting for covariates; no statistically significant change was observed in in-hospital mortality (-0.14%; 95% CI, -2.29% to 2.01%) or emergency readmission rate (-0.29%; 95% CI, -1.30% to 0.71%). In this cross-sectional study, the introduction of DRGs was associated with shorter lengths of stay and increased hospital volume, and discontinuation was associated with longer lengths of stay and decreased hospital volume. In-hospital mortality and emergency readmission rates did not significantly change after discontinuation of DRGs.

DeepDRG: Performance of Artificial Intelligence Model for Real-Time Prediction of Diagnosis-Related Groups.

Nowadays, the use of diagnosis-related groups (DRGs) has been increased to claim reimbursement for inpatient care. The overall benefits of using DRGs depend upon the accuracy of clinical coding to obtain reasonable reimbursement. However, the selection of appropriate codes is always challenging and requires professional expertise. The rate of incorrect DRGs is always high due to the heavy workload, poor quality of documentation, and lack of computer assistance. We therefore developed deep learning (DL) models to predict the primary diagnosis for appropriate reimbursement and improving hospital performance. A dataset consisting of 81,486 patients with 128,105 episodes was used for model training and testing. Patients’ age, sex, drugs, diseases, laboratory tests, procedures, and operation history were used as inputs to our multiclass prediction model. Gated recurrent unit (GRU) and artificial neural network (ANN) models were developed to predict 200 primary diagnoses. The performance of the DL models was measured by the area under the receiver operating curve, precision, recall, and F1 score. Of the two DL models, the GRU method, had the best performance in predicting the primary diagnosis (AUC: 0.99, precision: 83.2%, and recall: 66.0%). However, the performance of ANN model for DRGs prediction achieved AUC of 0.99 with a precision of 0.82 and recall of 0.57. The findings of our study show that DL algorithms, especially GRU, can be used to develop DRGs prediction models for identifying primary diagnosis accurately. DeepDRGs would help to claim appropriate financial incentives, enable proper utilization of medical resources, and improve hospital performance.

Refund Methods and Diagnosis-Related Groups Made to Health Institutions in Turkey

There are many difficulties in applying repayment methods. Reimbursement methods made to healthcare service providers determine an important quality in the provision of health services. The types of reimbursement methods made significantly affect the care services that patients should receive and the expenditures made. Repayment methods, the use of quality services that are tried to be put forward with the scarce resources available, act as a bridge between service providers and paying institutions. Because of this benefit, the use of Diagnosis-Related Groups and other payment methods, which are tried to be widespread, in health institutions, is tried to be made effective. In particular, the study focuses on the reimbursement methods made to health institutions in Turkey. In addition, the formation of Diagnosis-Related Groups in Turkey and the reimbursement methods based on Diagnosis-Related Groups in Turkey were mentioned. At the end of the study, it was seen how the repayments attempted to be made affect the distribution of financial resources among health institutions and how important it’s in dealing with the payment methods of Diagnosis-Related Groups was obtained. It’s thought that the study carried out will fill the gap in the literature and lead the future researches.

The Use of Diagnosis-Related Group-Based Reimbursement in the Czech Hospital Care System.

(1) Background: Diagnosis-Related Groups (DRG), one possibility of a hospital payment system, are currently used in most European countries. Introduced to the Czech system in the 1990s, the DRGs are currently used mainly for care reporting and partly for reimbursement. According to most experts, the use of DRG remain controversial. The goal of this paper was to study the effects of the current Czech DRG system on hospitals financing and, on this basis, to propose possible changes to the reimbursement mechanism in the Czech Republic. (2) Methods: Qualitative research methods were used for evaluating DRG mechanisms of application in three selected healthcare establishments in the CR in the period of 2012–2018. (3) Results: Our study shows that the current implementation of the DRG system is set up in a way that is very similar to traditional flat rates and is unlikely to yield major positive effects of the DRG mechanism, such as predictability of payments for hospitalisation cases, care quality and efficiency and transparent financing. (4) Conclusions: Based on our results, deep systemic change of the reimbursement mechanism in the Czech Republic is necessary. We propose five partial measures leading to the cultivation of the Czech DRG.

Are current DRG-based bundled payment models for lumbar fusions risk-adjusting adequately? An analysis of Medicare beneficiaries

BACKGROUND CONTEXTCurrent bundled payment programs in spine surgery, such as the bundled payment for care improvement rely on the use of diagnosis-related groups (DRG) to define payments. However, these DRGs may not be adequate enough to appropriately capture the large amount of variation seen in spine procedures. For example, DRG 459 (spinal fusion except cervical with major comorbidity or complication) and DRG 460 (spinal fusion except cervical without major comorbidity or complication) do not differentiate between the type of fusion (anterior or posterior), the levels/extent of fusion, the use of interbody/graft/BMP, indication of surgery (primary vs. revision) or even if the surgery was being performed for a vertebral fracture. PURPOSEWe carried out a comprehensive analysis to report the factors responsible for cost-variation in a bundled payment model for spinal fusions. STUDY DESIGNRetrospective review of a 5% national sample of Medicare claims from 2008 to 2014 (SAF5). OUTCOME MEASURESTo understand the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day costs for patients undergoing spinal fusions under DRG 459 and 460. METHODSThe 2008 to 2014 Medicare 5% standard analytical files (SAF) were used to retrieve patients undergoing spinal fusions under DRG 459 and DRG 460 only. Patients with missing gender, age, and/or state-level data were excluded. Only those patients who had complete data, with regard to payments/costs/reimbursements, starting from day 0 of surgery up to 90 days postoperatively were included to prevent erroneous collection. Multivariate linear regression models were built to assess the independent marginal cost impact (decrease/increase) of each patient-level, state-level, and procedure-level characteristics on the average 90-day cost while controlling for other covariates. RESULTSA total of 21,367 patients (DRG-460=20,154; DRG-459=1,213) were included in the study. The average 90-day cost for all lumbar fusions was $31,716±$18,124, with the individual 90-day payments being $54,607±$30,643 (DRG-459) and $30,338±$16,074 (DRG-460). Increasing age was associated with significant marginal increases in 90-day payments (70–74 years: +$2,387, 75–79 years: +$3,389, 80–84 years: +$2,872, ≥85: +$1,627). With regards to procedure-level factors—undergoing an anterior fusion (+$3,118), >3 level fusion (+$5,648) vs. 1 to 3 level fusion, use of interbody device (+$581), intraoperative neuromonitoring (+$1,413), concurrent decompression (+$768) and undergoing surgery for thoracolumbar fracture (+$6,169) were associated with higher 90-day costs. Most individual comorbidities were associated with higher 90-day costs, with malnutrition (+$12,264), CVA/stroke (+$5,886), Alzheimer's (+$4,968), Parkinson's disease (+$4,415), and coagulopathy (+$3,810) having the highest marginal 90-day cost-increases. The top five states with the highest marginal cost-increase, in comparison to Michigan (reference), were Maryland (+$12,657), Alaska (+$11,292), California (+$10,040), Massachusetts (+$8,800), and the District of Columbia (+$8,315). CONCLUSIONSUnder the proposed DRG-based bundled payment model, providers would be reimbursed the same amount for lumbar fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion (1–3 level vs. >3 level), use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated costs. When defining and developing future bundled payments for spinal fusions, health-policy makers should strive to account for the individual patient-level, state-level, and procedure-level variation seen within DRGs to prevent the creation of a financial dis-incentive in taking care of sicker patients and/or performing more extensive complex spinal fusions.

Patient-Centred Multidisciplinary Inpatient Care-Have Diagnosis-Related Groups an Effect on the Doctor-Patient Relationship and Patients' Motivation for Behavioural Change?

The aim of this, the largest survey of patients performed to date, is to analyse the effects of diagnosis related groups (DRGs) on the doctor-patient relationship in the context of interdisciplinary patient-centered care. In addition, it is intended to investigate the possibility of motivating patients to change their behavioural patterns and lifestyle in the context of holistic therapy. Over a period of five years, a continuous survey was performed of hospitalised patients who were exercising their entitlement to interdisciplinary therapy in an acute, inpatient setting. The therapy was evaluated as good to very good both with and without the conditions of the case tariff fee system. Effects of the diagnosis related groups on the quality of the doctor-patient relationship could not be demonstrated (Mann-Whitney U test, p>0,05). A clear trend was evident in the influence on motivation to change behavioural patterns and lifestyle (Fisher's exact test, p=0,000). Studies of the effects of reimbursement systems in the context of interdisciplinary care are still in their infancy, despite the widespread use of diagnosis related groups. The mandatory character implicit in the case tariff fee system, which requires minimum qualitative standards for structural and procedural parameters in the context of providing interdisciplinary patient-centered care, can influence patients' behavioural patterns and lifestyle.

Impact of new health care policies on the quality of acute myocardial infarction treatment in Swiss hospitals: A before and after observational study

Objective: Following a revision of the Swiss Federal Health Insurance Act, the regional hospital planning structure was modified and the hospital financing organized at a national level with the use of diagnosis related groups (SwissDRGs). The aim of this observational study was to determine in an independent way the initial impact of these changes on the quality of hospital treatment, with patients hospitalized for Acute Myocardial Infarction (AMI) being the chosen study group.Methods: We used prospective data from a Swiss clinical registry for AMI. The quality was measured based on the adherence to 10 evidence-based performance indicators for AMI treatment, and on the evaluation of in-hospital outcomes (mortality, complications, length of hospital stay [LOS]) globally and for seven pre-defined vulnerable subgroups. The study compared patient-based data before (2011) and after (2012) the implementation of the reform.Results: The study included 33 matched hospitals, and compared the AMI treatment of 2,491 patients in 2011 (before) and 2,544 in 2012 (after the hospital reform). No significant changes in the evidence-based performance indicators were observed, but an on average one day reduction in the LOS and worse outcomes in one of the pre-defined group of patients were found. The issue of how the clinical team achieved these results was not directly explored due to the underlying registry’s unalterable structure.Conclusions: One year after the implementation of a new hospital financing system in Switzerland, the quality of treatment delivered to patients hospitalized for AMI was maintained overall. The worse in-hospital mortality in one pre-defined vulnerable subgroup could reflect the emergence of difficulties for clinical teams to cope with patients demanding extra care and time. Further investigation is warranted.

Payment Reform Pilot In Beijing Hospitals Reduced Expenditures And Out-Of-Pocket Payments Per Admission.

In 2009 China announced plans to reform provider payment methods at public hospitals by moving from fee-for-service (FFS) to prospective and aggregated payment methods that included the use of diagnosis-related groups (DRGs) to control health expenditures. In October2011 health policy makers selected six Beijing hospitals to pioneer the first DRG payment system in China. We used hospital discharge data from the six pilot hospitals and eight other hospitals, which continued to use FFS and served as controls, from the period 2010-12 to evaluate the pilot's impact on cost containment through a difference-in-differences methods design. Our study found that DRG payment led to reductions of 6.2percent and 10.5percent, respectively, in health expenditures and out-of-pocket payments by patients per hospital admission. We did not find evidence of any increase in hospital readmission rates or cost shifting from cases eligible for DRG payment to ineligible cases. However, hospitals continued to use FFS payments for patients who were older and had more complications than other patients, which reduced the effectiveness of payment reform. Continuous evidence-based monitoring and evaluation linked with adequate management systems are necessary to enable China and other low- and middle-income countries to broadly implement DRGs and refine payment systems.

Diagnosis-Related Groups (DRG) and Hospital Business Performance Management

Abstract The goal of this article is to present the possibility of using Diagnosis- Related Groups (DRG) in the hospital management process and to analyse the need for business performance management on the part of hospital management staff. The following research methods were used: literature analysis, case studies, and poll analysis. It is not possible to increase the effectiveness of operation of healthcare entities without increasing the importance of IT systems and using DRG more effectively in the management process. Training users in IT and the use of DRGs is important to achieving hospital effectiveness. The increased importance of analyses and planning in a hospital should be reflected in the organisational structure of service providers. Hospital controllers should have a similar role to those present in most companies in other industries.

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis.

BackgroundActivity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care.MethodsWe undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication.ResultsOf 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk = 1.24, 95% CI 1.18–1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences.ConclusionsTransitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

Hospital Payment Based On Diagnosis-Related Groups Differs In Europe And Holds Lessons For The United States

England, France, Germany, the Netherlands, and Sweden spend less as a share of gross domestic product on hospital care than the United States while delivering high-quality services. All five European countries have hospital payment systems based on diagnosis-related groups (DRGs) that classify patients of similar clinical characteristics and comparable costs. Inspired by Medicare's inpatient prospective payment system, which originated the use of DRGs, European DRG systems have implemented different design options and are generally more detailed than Medicare's system, to better distinguish among patients with less and more complex conditions. Incentives to treat more cases are often counterbalanced by volume ceilings in European DRG systems. European payments are usually broader in scope than those in the United States, including physician salaries and readmissions. These European systems, discussed in more detail in the article, suggest potential innovations for reforming DRG-based hospital payment in the United States.

Bundling Acute and Postacute Payment: From a Culture of Compliance to a Culture of Innovation and Best Practice

Buried deep in the Patient Protection and Affordable Care Act (HR 3590; Pub L No. 111-148)1 are proposals to bundle acute and postacute payment into one payment for services provided to Medicare beneficiaries within the 30 days postdischarge from the acute care hospital. The concept of bundling payment appears to have gained sufficient traction that it will endure as a topic of debate.2,3 Bundling, or episode payment, has not been a part of the public debate about health care reform. Politicians rarely, if ever, mention it—in part because they know that the public is not easily engaged in technical issues of acute and postacute payment that are largely invisible to them. Yet, bundling acute and postacute payment represents one of the most far-reaching proposals for Medicare reform since 1983, when Congress authorized the use of diagnosis-related groups (DRGs) as the basis for classifying Medicare beneficiaries under a prospective payment system (PPS) for acute hospital care. Bundling promises to reshape the way we manage a patient’s care over a given episode of care. It offers enormous opportunities to enhance patient care while reducing costs, but it also poses significant design challenges that, if not handled correctly, can have unintended effects and undermine patient well-being. I will examine these opportunities and challenges primarily, but not solely, from the perspective of postacute care, a major practice area for physical therapists. Most of the observations made here generalize to both the acute and postacute portions of an episode of care. In fact, with bundling, some of the distinctions between acute care and postacute care may begin to lose some of their meaning. Bundling acute and postacute payment is not a new concept.4 The concept surfaced in the mid 1980s in the aftermath of the new DRG-based PPS for hospital …

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.

Changes in the utilization of diagnostic codes in neonatology following the introduction of activity-based financing

Activity-based financing was introduced in public hospitals in Norway in 1997. Following this, hospitals have been financed in part by block grants, in part by grants based on productivity as measured through weighted diagnosis-related groups (DRGs). Insufficient national data were available to allow for proper calculation of DRG weights for neonatology. Thus, data from other countries were used to estimate weights. It seemed of interest to examine whether the use of diagnostic codes in neonatal medicine was changed following the introduction of activity-based financing and DRGs. Data from 1994, 1996, 1998, and 2000 were obtained from the proprietary database of the NICU at Rikshospitalet, University of Oslo, as well as from the hospital Patient Information Management System. Diagnoses were organized into 39 categories, counted for each of the 4 years, and analyzed by non-parametric ANOVA. There were significant changes in the use of diagnostic categories during the 1994–2000 time period. Some diagnoses which previously have been only rarely used, became more frequent. The use of other diagnoses varied in ways that could only be understood in terms of tactical usage. It is concluded that the use of DRGs as a basis for activity-based financing may result in changes in the use of certain diagnostic categories which are not related to biological changes in the patient population. This may complicate epidemiological research. On the other hand, activity-based financing may result in increased attention to the diagnostic process, leading to increased use of secondary diagnoses and thus more complete diagnostic coding.

Optimizing coding and reimbursement to improve management of Alzheimer's disease and related dementias.

The objectives of this study were to review the diagnostic, International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM), diagnosis related groups (DRGs), and common procedural terminology (CPT) coding and reimbursement issues (including Medicare Part B reimbursement for physicians) encountered in caring for patients with Alzheimer's disease and related dementias (ADRD); to review the implications of these policies for the long-term clinical management of the patient with ADRD; and to provide recommendations for promoting appropriate recognition and reimbursement for clinical services provided to ADRD patients. Relevant English-language articles identified from MEDLINE about ADRD prevalence estimates; disease morbidity and mortality; diagnostic coding practices for ADRD; and Medicare, Medicaid, and managed care organization data on diagnostic coding and reimbursement were reviewed. Alzheimer's disease (AD) is grossly undercoded. Few AD cases are recognized at an early stage. Only 13% of a group of patients receiving the AD therapy donepezil had AD as the primary diagnosis, and AD is rarely included as a primary or secondary DRG diagnosis when the condition precipitating admission to the hospital is caused by AD. In addition, AD is often not mentioned on death certificates, although it may be the proximate cause of death. There is only one ICD-9-CM code for AD-331.0-and no clinical modification codes, despite numerous complications that can be directly attributed to AD. Medicare carriers consider ICD-9 codes for senile dementia (290 series) to be mental health codes and pay them at a lower rate than medical codes. DRG coding is biased against recognition of ADRD as an acute, admitting diagnosis. The CPT code system is an impediment to quality of care for ADRD patients because the complex, time-intensive services ADRD patients require are not adequately, if at all, reimbursed. Also, physicians treating significant numbers of AD patients are at greater risk of audit if they submit a high frequency of complex codes. AD is grossly undercoded in acute hospital and outpatient care settings because of failure to diagnose, limitations of the coding system, and reimbursement issues. Such undercoding leads to a lack of recognition of the effect of AD and its complications on clinical care and impedes the development of better care management. We recommend continuing physician education on the importance of early diagnosis and care management of AD and its documentation through appropriate coding, expansion of the current ICD-9-CM codes for AD, more appropriate use of DRG coding for ADRD, recognition of the need for time-intensive services by ADRD patients that result in a higher frequency of use of complex CPT codes, and reimbursement for CPT codes that cover ADRD care management services.

Predicting the cost of hospital stay for stroke patients: the use of diagnosis related groups

In order to provide tailor-made care, governments are considering the implementation of output-pricing based on hospital case-mix measures, such as diagnosis related groups (DRG). The question is whether the current DRG classification system can provide a satisfactory prediction of the variance of costs in stroke patients and if not, in what way other variables may enhance this prediction. In this study, data from 731 stroke patients hospitalized at University Hospital Maastricht during 1996–1998 are used in the cost analysis. The DRG classification for this group uses information—in addition to the DRG classification operation or no operation—on the patient's age combined with discharge status. The results of regression analysis show that using DRGs, the variance explained in the costs amounts to 34%. Adding other variables to the DRGs, the variance explained increases to about 61%. Additional factors highly correlating with inpatient costs are the level of functioning after stroke, comorbidity, complications, and ‘days of stay for non-medical reasons’. Costs decreased for stroke patients discharged during the latter part of the years studied, and if stroke patients happened to die during their hospital stay. The results do suggest that future implementation of output-pricing based on the DRG case-mix measures is feasible for stroke patients only if it is enhanced with information on complications and the level of functioning.

Casemix funding in Australia.

Casemix funding for hospitals with the use of diagnosis-related groups (DRGs), which organise patients' conditions into similar clinical categories with similar costs, was introduced in Australia five years ago. It has been applied in different ways and to a greater or lesser extent in different Australian States. Only Victoria and South Australia have implemented casemix funding across all healthcare services. Attempts have been made to formally evaluate its impact, but they have not met the required scientific standards in controlling for confounding factors. Casemix funding remains a much-discussed issue. In this Debate, Braithwaite and Hindle take a contrary position, largely to stimulate policy debate; Phelan defends the casemix concept and advocates retaining its best features; and Hanson adds a plea for consumer input.

Reduced length of stay following carotid endarterectomy under general anesthesia

Background: The widespread use of diagnosis-related groups has led to a significant reduction in the length of hospital stay following many surgical procedures. In light of this, an examination of early discharge following carotid endarterectomy under general anesthesia was undertaken. Patients and methods: A prospective study of 72 patients was conducted, in which the workup was done on an outpatient basis, admission took place on the same day as surgery, and patients were discharged home on the day after carotid endarterectomy. Results: There were no strokes or deaths following carotid endarterectomy, and only two transient ischemic attacks occurred. In 88% of the cases, discharge was possible on the first postoperative day. Conclusions: Early discharge following carotid endarterectomy under general anesthesia is safe and cost effective.