Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference

Patients requiring prolonged mechanical ventilation (PMV) are rapidly increasing in number, as improved ICU care has resulted in many patients surviving acute respiratory failure only to then require prolonged mechanical ventilatory assistance during convalescence. This patient population has clearly different needs and resource consumption patterns than patients in acute ICUs, and specialized venues, management strategies, and reimbursement schemes for them are rapidly emerging. To address these issues in a comprehensive way, a conference on the epidemiology, care, and overall management of patients requiring PMV was held. The goal was to not only review existing practices but to also develop recommendations on a variety of assessment, management, and reimbursement issues associated with patients requiring PMV. Formal presentations were made on a variety of topics, and writing groups were formed to address three specific areas: epidemiology and outcomes, management and care settings, and reimbursement. Each group was charged with summarizing current data and practice along with formulation of recommendations. A working draft of the products of these three groups was then created and circulated among all participants. The document was reworked with input from all concerned until a final product with consensus recommendations on 12 specific issues was achieved.

The care of elderly patients with hip fracture. Changes since implementation of the prospective payment system

We hypothesized that the care provided to elderly patients with hip fracture in community hospitals has changed since the implementation of prospective payment systems (PPS) in 1983. We reviewed records of elderly patients admitted with hip fracture to a large community hospital from 1981 to 1986. During that period, the mean length of hospitalization decreased (from 21.9 to 12.6 days; P less than 0.0001), inpatient physical therapy decreased (from 7.6 to 6.3 sessions; P less than 0.04), and the maximal distance walked before discharge fell (from 27 to 11 m [93 to 38 ft]; P less than 0.0001). Concomitantly, the proportion of patients discharged to nursing homes rose (from 38 to 60 percent; P less than 0.0001), as did the proportion remaining in nursing homes one year after hospitalization (from 9 to 33 percent; P less than 0.0001). Neither in-hospital mortality nor one-year mortality changed significantly. As compared with beneficiaries of conventional Medicare after the implementation of PPS, HMO enrollees had shorter hospitalizations (7.3 vs. 14.0 days; P less than 0.0001), received less physical therapy (3.5 vs. 7.1 sessions; P less than 0.0001), walked shorter distances at discharge (3 vs. 13 m [11 vs. 44 ft]; P less than 0.01), and were more frequently transferred to nursing homes (83 vs. 55 percent; P less than 0.01). One year later, however, fewer HMO patients remained in nursing homes (16 vs. 35 percent; P less than 0.07). We conclude that since the implementation of PPS, hospitals have reduced the amount of care given to patients with hip fracture and have shifted much of the rehabilitation burden to nursing homes. The increase in the number of such patients remaining in nursing homes one year after the fracture suggests that the overall quality of care for these patients may have deteriorated.

The effects of hospital competition and the Medicare PPS program on hospital cost behavior in California

Previous studies of hospital competition have found that greater competition leads to higher hospital costs. In this paper we report how the behavior of California's hospitals has changed since the introduction of programs intended to contain the rate of increase of hospital costs. Using data that cover the period preceding and following the introduction of these programs, we found that hospitals in more competitive markets have lowered their costs significantly.

A case-mix classification system for medical rehabilitation

Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.

Methods to determine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries

Over the past 20 years, most European countries have introduced DRGs or similar grouping systems as instruments for hospital reimbursement. This paper compares and analyzes the methods used to determine prices for inpatient care within DRGs or similar grouping systems employed in nine EU member states (i.e., Denmark, France, Germany, Hungary, Italy, Tthe Netherlands, Poland, Spain and England). It categorizes the systems of patient classification used in these nine countries and compares them according to the three steps necessary in order to set prices: 1.) definition of a data sample, 2.) use of trimming methods and plausibility checks and 3.) definition of prices. It concludes with a discussion on the typical development path of DRG systems and the role of additional reimbursement components in this context.

The increased needs of patients in nursing homes and patients receiving home health care

To evaluate the effects of Medicare's prospective payment system and Medicaid's preadmission regulations on long-term care, we constructed clinical profiles in 1982 and 1986 of about 500 randomly selected patients from each of three types of facilities: nursing homes with relatively high proportions of Medicare patients (high-Medicare nursing homes; n = 23), traditional nursing homes (n = 19), and home health agencies (n = 18). Data were obtained directly from the care givers on the medical problems, problems requiring skilled nursing, and functional problems of these representative patients from 12 states. For Medicare patients in high-Medicare nursing homes, the prevalence of medical problems and problems requiring skilled nursing increased substantially, whereas the prevalence of functional problems remained relatively unchanged. For example, from 1982 to 1986 there was a marked increase in the frequency of tube feedings (21 to 29 percent), oxygen use (6 to 14 percent), urinary tract infection (7 to 13 percent), and diastolic hypertension (1 to 10 percent), but not difficulty in eating (48 to 51 percent) or speaking (28 to 29 percent). In contrast, in traditional nursing homes there was an increase in the prevalence of functional disability, but virtually no change in that of problems requiring medical and skilled nursing care. In home health care the functional care needs of Medicare patients increased significantly, and there was a slight increase in the prevalence of problems requiring medical and skilled nursing care. We conclude that from 1982 to 1986 the needs of patients in long-term care increased substantially. This trend appears to result from Medicare's prospective payment system, which encourages earlier hospital discharge to long-term care settings, and from Medicaid's policy of de-institutionalization. Meeting this greater need for care will be costly. We require a better system of reimbursing for long-term care and ensuring its quality.

"ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care

OBJECTIVE

To test whether an integrated delivery system could successfully implement an evidence-based pay-for-performance program for coronary artery bypass graft (CABG) surgery.

METHODS

The program consisted of 3 components: (1) establishing implementable best practices; (2) developing risk-based pricing; (3) establishing a mechanism for patient engagement. Surgeons reviewed all class I and IIa "2004 American Heart Association/American College of Cardiology Guidelines for CABG Surgery" and translated them into 40 verifiable behaviors. These were imbedded within a new ProvenCareSM program and "hardwired" within the electronic health record system, including order sets, templates, and "time outs". Concurrently preoperative, inpatient, and postoperative care within 90 days was packaged into a fixed price. A Patient Compact was developed to highlight the importance of patient activation. All elective CABG patients treated between February 2, 2006 and February 2, 2007 were included (ProvenCareSM Group) and compared with 137 patients treated in 2005 (Conventional Care Group).

RESULTS

Initially, only 59% of patients received all 40 best practice components. At 3 months, program compliance reached 100%, but fell transiently to 86% over the next 3 months. Reliability subsequently increased to 100% and was sustained for the remainder of the study period. The overall trend in reliability was significant at P=0.001. Thirty-day clinical outcomes showed improved trends () but only the likelihood of discharge to home reached statistical significance. Length of stay decreased by 16% and mean hospital charges fell 5.2%.(Table is included in full-text article.)

CONCLUSION

A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.

Possible influence of the prospective payment system on the assignment of discharge diagnoses for coronary heart disease

BACKGROUND

The prospective payment system, under which diagnosis-related groups (DRGs) are used to reimburse hospitals for the care of Medicare patients, replaced the fee-for-service method of payment in Rhode Island in 1983 and in Massachusetts in 1985. Changes in financial incentives resulting from the use of the DRG system may have influenced the assignment of discharge diagnostic codes away from those with lower reimbursement toward codes with higher reimbursement.

METHODS

We collected data from the hospital records of patients 35 through 74 years of age who were discharged with codes 410 through 414 (representing various categories of coronary heart disease) of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The patients were discharged from seven hospitals in two New England communities (one in Rhode Island and one in Massachusetts) between 1980 and 1988. The rates of diagnosis of various forms of coronary heart disease were determined by studying ICD-9-CM hospital discharge codes (codes 410 and 411 for acute forms of coronary heart disease and codes 412, 413, and 414 for chronic forms) and by using a computerized diagnostic algorithm designed to detect definite myocardial infarction and fatal coronary heart disease.

RESULTS

The rates of definite coronary events diagnosed by the algorithm and by the study of ICD-9-CM codes 410 through 414 were constant or increased slightly during the study period. However, the frequency of assignment of codes for the acute forms of coronary heart disease (which entail higher reimbursement) rose from 35.2 percent to 48.4 percent among discharged patients with cardiac disease after the institution of DRGs. The majority of this increase was associated with the code for unstable angina pectoris. The frequency of assignment of codes for the chronic forms of coronary heart disease (which entail lower reimbursement) decreased reciprocally, from 64.8 percent to 51.6 percent (P < 0.001).

CONCLUSIONS

Our data are consistent with the hypothesis that the prospective reimbursement system has influenced the assignment of hospital discharge codes in a way that would increase payment to hospitals. However, the data do not permit us to distinguish whether hospitals began to assign more precise diagnoses with the advent of the DRG system, or whether they began to favor diagnoses of acute conditions solely for financial reasons.

Treatment of pruritus with topically applied opiate receptor antagonist

BACKGROUND

Pruritus is the most common and distressing skin symptom, and treatment of itch is a problem for thousands of people. The currently available therapies are not very effective. Therefore there is an urgent need to find new effective topical drugs against itching.

OBJECTIVE

We conducted two separate studies to evaluate the efficacy of topically applied naltrexone, an opioid receptor antagonist, in the treatment of severe pruritus. The objective of the first open study was to correlate the clinical efficacy of topically applied naltrexone in different pruritic skin disorders to a change of epidermal mu-opiate receptor (MOR) expression. The second study was a double-blind, placebo-controlled, crossover study on pruritus in atopic dermatitis.

METHODS

Initially we performed an open pilot study on 18 patients with different chronic pruritic disorders using a topical formulation of 1% naltrexone for 2 weeks. A punch biopsy was performed in 11 patients before and after the application of the naltrexone cream and the staining of epidermal MOR was measured. Subsequently, a randomized, placebo-controlled, crossover trial was performed with the same formulation. We included in this trial 40 patients with localized and generalized atopic dermatitis with severe pruritus.

RESULTS

In the open study more than 70% of the patients using the 1% naltrexone cream experienced a significant reduction of pruritus. More interestingly, the topical treatment with naltrexone caused an increase of epidermal MOR staining. The regulation of the epidermal opioid receptor correlated with the clinical assessment. The placebo-controlled, crossover trial demonstrated clearly that the cream containing naltrexone had an overall 29.4% better effect compared with placebo. The formulation containing naltrexone required a median of 46 minutes to reduce the itch symptoms to 50%; the placebo, 74 minutes.

LIMITATIONS

We could only take biopsy specimens in 11 patients, which means that a satisfactory statistical analysis of the changes of epidermal MOR staining was not possible. In addition, there was an insufficient number of patients with nephrogenic pruritus and pruritic psoriasis to draw definitive conclusions.

CONCLUSIONS

The placebo-controlled study showed a significant advantage of topically applied naltrexone over the placebo formulation. This finding is supported by the biopsy results from the open studies, showing a regulation of MOR expression in epidermis after treatment with topical naltrexone, especially in atopic dermatitis. These results clearly show potential for topically applied opioid receptor antagonist in the treatment of pruritus. The placebo formulation also had some antipruritic effects. This underlines the importance of rehydration therapy for dry skin in the treatment of pruritus.

Functional outcomes of posthospital care for stroke and hip fracture patients under medicare

BACKGROUND

Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge.

METHODS

Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA).

RESULTS

In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement.

CONCLUSIONS

The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

Editorial: Hospital case payment systems in Europe

Since the introduction of the system of diagnosis related groups (DRGs) for USA Medicare patients in 1983, case payment mechanisms have gradually become the principal means of reimbursing hospitals in most developed countries. The use of case payments nevertheless poses severe technical and policy challenges, and there remain many unresolved issues in their implementation. This paper introduces a special issue of the journal that describes and compares experience with the use of case payments for reimbursing hospitals in nine European countries. The editorial sets the policy scene, and argues that DRG systems must be seen both as a technical reimbursement method and as a fundamental incentive mechanism within the health system.

Contribution of a measure of disease complexity (COMPLEX) to prediction of outcome and charges among hospitalized patients

Attention has been focused on the need to adjust hospital reimbursement and outcomes of hospital care for level of illness. Extant measures of disease severity, however, fail to consider the contribution of disease complexity. We developed an easily retrievable measure of disease complexity (COMPLEX) by modifying an existing severity system, computerized Disease Staging. The contribution of COMPLEX (the number of body systems affected with a Disease Staging score of 2 or more) to the prediction of outcome was assessed in two studies: (1) a population-based analysis of readmission and mortality after hospitalization and (2) an analysis of hospital charges among patients who were in an intensive-care unit. The amount of variation in mortality explained by factors included in the Health Care Financing Administration model was significantly improved when COMPLEX was added to the model (adjusted odds ratio per body system, 1.83; 95% confidence interval, 1.61 to 2.08). A significant association was also observed between COMPLEX score and hospital readmission after adjustment for age, sex, case-mix, and disease severity (adjusted odds ratio, 1.31; 95% confidence interval, 1.20 to 1.44). When COMPLEX was added to case-mix and disease severity in a model for predicting hospital charges, the percentage of variation in hospital charges explained by the model increased from 25% to 38%. These findings demonstrate the important contribution of disease complexity to the analysis of outcome of medical care and utilization of resources. Outcome or reimbursement models that do not incorporate disease complexity may negatively affect institutions with a high proportion of patients who have complex conditions.

Nutritional assessment and management in hospitalised patients: Implication for DRG-based reimbursement and health care quality

INTRODUCTION

Malnutrition is associated with a higher morbidity resulting in an increased need for medical resources and economic expenses. In order to ensure sufficient nutritional care it is mandatory to identify the effect of malnutrition and nutritional care on direct cost and reimbursement. The primary aim of this study was to evaluate the economic effect of a nutritional screening procedure on the identification and coding of malnutrition in the G-DRG system.

METHODS

All G-DRG relevant parameters of 541 consecutive patients at a gastroenterology ward were documented. Moreover, all patients were screened for malnutrition by a dietician according to the subjective global assessment (SGA). Patients were then grouped into the appropriate G-DRG and the effective cost weight (CW) was calculated.

RESULTS

Ninety-two of 541 patients (19%) were classified malnourished (SGA B or C). Recognition of malnutrition increase from 4% to 19%. Malnourished patients exhibited a significantly increased length of hospital stay (7.7+/-7 to 11+/-9, P<0.0001). In 26/98 (27%) patients, the coding of malnutrition was considered relevant by grouping and resulted in a rise of DRG benefit. Mean case mix value and patients' complexity and comorbidity level (PCCL) increased after including malnutrition in the codification (CV 1.53+/-2.9 to 1.65+/-2.9, P=0.001 and PCCL 2.69+/-1.4 to 3.47+/-0.82, P<0.0001). The reimbursement increase by 360/malnourished patient or an additional reimbursement of 35280 (8.3% of the total reimbursement for all patients of 423186). Nutritional support in a subgroup of 50 randomly selected patients resulted in additional costs of 10268 . Forty-four of these patients (86%) were classified malnourished (32 SGA B and 12 SGA C). However, the subsequent reimbursement covered only approximately 75% of the expenses (7869), but did not include the potential financial benefits resulting from clinical interventions.

CONCLUSION

Malnourished patients can be detected with a structured assessment and documentation of nutritional status and this is partly reflected in the G-DRG/ICD 10 system. In addition to increasing direct health care reimbursement, nutritional screening and intervention has the potential to improve health care quality.

Refining case-mix adjustment. The research evidence

We review case-mix adjustment, which is the process of adjusting for differences in the cases treated in different hospitals so that their costs or outcomes can be compared. We examine the Medicare payment system, which rests on case-mix adjustment, and identify areas, including outlier payments, in which payment accuracy might be improved without better measurement of the severity of illness. There is no available measure of severity of illness that would produce a large improvement in the accuracy of Medicare payments if used to supplement or replace the system of diagnosis-related groups. Evidence regarding whether better measurement of severity would substantially change the distribution of payments across hospitals is mixed. Considerable evidence suggests that the intensity of medically appropriate treatment for patients in the same diagnosis-related group varies substantially for reasons other than the severity of illness. Despite great demand for measures of the quality of care, important technical problems must be solved before we can be confident that differences in case-mix-adjusted outcomes reflect differences in the quality of care.

A model for management of patients with stroke during the acute phase. Outcome and economic implications

BACKGROUND AND PURPOSE

The purpose of the study was to develop a clinical pathway for patients with nonhemorrhagic stroke during the acute hospital phase to improve the quality of care and reduce costs.

METHODS

The pathway included standard admission orders and a swallow screen on day 1 of hospitalization. Physical therapy, occupational therapy, speech therapy, and social worker assessments were done on day 2. A physiatry consult was performed on day 3 if indicated, and by day 4 a discharge target date and disposition were addressed.

RESULTS

Outcomes for 121 patients during the first year of pathway implementation are reported. The average length of stay on the acute service decreased from 10.9 days to 7.3 days (P < .05), reducing the charges per patient by 14.6%. Complications in the form of urinary tract infections and aspiration pneumonia rates decreased by 63.2% (P < .05) and 38.7%, respectively.

CONCLUSIONS

We conclude that the implementation of a clinical pathway for patients with acute, nonhemorrhagic stroke resulted in a significant reduction in length of stay, charges, and complications while improving the quality of care.

Nosocomial infections, diagnosis-related groups, and study on the efficacy of nosocomial infection control. Economic implications for hospitals under the prospective payment system

It is obvious that escalating costs of medical care must be curbed. Fortunately, since the major proportion of health care costs relate to inpatient management, the diagnosis-related group "experiment" forces the medical community to examine carefully the costs of the specific components of health care delivery. One such item is the cost of nosocomial infections. With respect to the potential importance of hospital-acquired infections and reimbursement under the diagnosis-related group system, several points should be underscored. Nosocomial infections represent a direct economic liability of $5 to $10 billion annually in the United States. Under the new diagnosis-related group reimbursement system, it is probable that very little of the costs related to excess stay resulting from infections will be reimbursed to hospitals. For the first time, there are data indicating that as much as one third of hospital-acquired infections can be prevented by implementing effective infection control programs. The currently available information suggests that under the existing diagnosis-related group reimbursement system, hospitals with effective infection control programs can significantly improve their economic position.

Medicare hospital payment by diagnosis-related groups

On 1 October 1983, the Medicare system began a phased transition to a new payment method for hospitals based on uniform payments by diagnosis-related group (DRG). This article reviews the rationale for DRG-based reimbursement, describes the new Medicare system, and discusses its implications for hospitals, physicians, and hospital-physician relations. Although it is too early to evaluate its impact, this payment system will probably encourage more operational interaction between hospital administrators and organized medical staffs, and accelerate trends towards salaried service chiefs in community hospitals and greater external scrutiny of physicians' activities.

Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system?

Germany has recently introduced a system of Diagnosis Related Groups (DRGs) to engender more appropriate resource allocation. The following article describes the German DRG-system and the methodologies used to determine prices. It analyses the extent to which prices, or calculated cost weights, reflect the actual costs incurred by hospitals for their respective services. We reveal that a "compression" of DRG cost weights occurs, and that the data sample used to calculate cost weights is lacking in terms of its representativeness. Although cost data accuracy has improved over the last few years there are still a number of challenges that need to be addressed.

The effectiveness of a regulatory strategy in containing hospital costs. The Ontario experience, 1967-1981

This study documents the increases in real inputs (e.g., labor and equipment) employed in Ontario's hospital sector between 1968 and 1981--a period of universal government-financed hospital insurance and a government regulatory strategy involving global budgeting. Total expenditures in Ontario increased by only 16 per cent in terms of real inputs, as compared with an increase of 101 per cent in the United States. Real inputs per patient-day increased at a mean annual rate of 0.68 per cent in Ontario versus 5.19 per cent in the United States (P less than 0.001). Real inputs per admission decreased at a mean annual rate of 1.12 per cent in Ontario, as compared with an increase of 4.15 per cent in the United States (P less than 0.0001). We conclude that regulation can contain the growth of real inputs employed in the hospital sector even in the face of an incentive structure that does not promote cost consciousness on the part of patients or physicians. Although the effect of this strategy on the quality of care is unknown, so far it appears to have been politically acceptable in Ontario.