Knee replacement and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries

DRGKB: a knowledgebase of worldwide diagnosis-related groups' practices for comparison, evaluation and knowledge-guided application

As a prospective payment method, diagnosis-related groups (DRGs)'s implementation has varying effects on different regions and adopt different case classification systems. Our goal is to build a structured public online knowledgebase describing the worldwide practice of DRGs, which includes systematic indicators for DRGs' performance assessment. Therefore, we manually collected the qualified literature from PUBMED and constructed DRGKB website. We divided the evaluation indicators into four categories, including (i) medical service quality; (ii) medical service efficiency; (iii) profitability and sustainability; (iv) case grouping ability. Then we carried out descriptive analysis and comprehensive scoring on outcome measurements performance, improvement strategy and specialty performance. At last, the DRGKB finally contains 297 entries. It was found that DRGs generally have a considerable impact on hospital operations, including average length of stay, medical quality and use of medical resources. At the same time, the current DRGs also have many deficiencies, including insufficient reimbursement rates and the ability to classify complex cases. We analyzed these underperforming parts by domain. In conclusion, this research innovatively constructed a knowledgebase to quantify the practice effects of DRGs, analyzed and visualized the development trends and area performance from a comprehensive perspective. This study provides a data-driven research paradigm for following DRGs-related work along with a proposed DRGs evolution model. Availability and implementation: DRGKB is freely available at http://www.sysbio.org.cn/drgkb/. Database URL: http://www.sysbio.org.cn/drgkb/.

A Bibliometric Analysis of Diagnosis Related Groups from 2013 to 2022

Purpose

As an important management method of the global healthcare system, diagnosis related groups (DRGs) classify patients into different cost groups and pay more attention to the equitable distribution of medical resources and the quality of medical services. At present, most countries have used DRGs to help medical institutions and doctors to treat patients more accurately, avoid the waste of medical resources, and improve treatment efficiency.

Methods

The Web of Science database was searched to collect all relevant literature on DRGs from 2013 to 2022. The literature information was imported into CiteSpace, Vosviewer, and Histcite for data analysis and visualization of the results. Analyze the cooperative relationship among the countries, institutions, journals, and authors. The usage trend of keywords; Highlight the content of the cited articles.

Results

The number of articles published in this decade was stable, and the number of citations in 2014 was the highest. The United States and Germany, as the first countries to use the DRGs system, are ahead of other countries in terms of the number and quality of articles. We have carried out content research on the articles with high citations, and summarized the application range of DRGs; classification method; advantages and disadvantages of the application. In general, the development trend of DRGs in foreign countries is to continuously optimize the classification method, expand the scope of application, and improve the application effect. These provide support and reference for the improvement of medical services and the perfection of the medical insurance system.

Conclusion

The application of DRGs can improve the quality and efficiency of medical services, and reduce the waste of medical expenses. It can also promote the rational allocation of medical resources and the equity of medical services. In the future, DRGs will pay more attention to the personalized diagnosis and treatment and fine management of patients, and the sharing and standardization of medical data, to promote the development of medical informatization.

Financial Impact of Inaccurate Coding Plus Cost-Effectiveness Analysis for Surgically Managed Patients With Periprosthetic Fractures

Background

An upward trend is seen in a number of periprosthetic fractures. Their management often requires complex surgical intervention, expert skills and expensive equipment. Hospitals get paid according to Healthcare Resource Group (HRG) tariffs. HRG gets generated once diagnoses, Charlson comorbidity (CC) index score, surgical procedures, investigations and length of stay have been coded for. Coding departments consist of non-clinicians. Although auditing systems are in and made of internal and external auditors, we hypothesized that multiple errors can still occur which may result in significant financial losses.

Objectives

To assess the accuracy of coding for management of periprosthetic fractures. To identify causes for inaccurate coding and assess the financial impact of highly complex trauma in a district general hospital (DGH).

Methods

Retrospective comparative analysis of case notes for patients with an M966 diagnosis code (periprosthetic fracture) between 1st November 2017 and 1st November 2018. All cases were analysed and data for primary procedure, primary diagnosis, secondary procedures and secondary diagnosis, comorbidities and length of stay were extrapolated and re-coded using the same software in use by the coding team. Costs incurred for each surgically managed patient were calculated using a rough estimate of cost of each procedure. Finally, cost-effectiveness analysis was carried out by comparing our calculated figures to the actual final claim by our institution. 

Results

Twenty-nine patients with the diagnosis of periprosthetic fracture were identified by the coding team using M966 code. A further case was identified by reviewing operating software (Operating Room Management Information System [ORMIS®]). In four cases (13.3 %), the primary diagnosis was coded incorrectly by the coding team. Overall coders accuracy for surgically managed patients (n=21) was 52% (n=11). This resulted in an estimated incurred loss of £25,000. Wrong/omitted site of surgery was found to be the most influential coder error with up to £8000 loss in one case (P<0.05). Cost-effectiveness analysis demonstrated the stark differences in costs for HRG tariffs when used in trauma setting vs non-trauma setting. Open reduction and internal fixation (ORIF) was associated with less financial loss to our trust with closer procedural costs to HRG tariff (average cost of £9200 for ORIF vs £22,030 for a massive endoprosthesis).

Conclusions

Surgeons should carefully review codes for such complex procedures before or soon after surgery. Wrong/omitted site of surgery is the key cause for losses in our cohort, followed by inadequate recording of comorbidities. Coders can only code for what is documented. Following cost-effectiveness analysis our study highlights the need for HRG tariffs to be revised for such procedures. The cost of ORIF vs massive endoprosthesis should be noted, signifying the implant costs when such specialised revision surgery performed over less expensive ORIF surgery.

Challenges and Adverse Outcomes of Implementing Reimbursement Mechanisms Based on the Diagnosis-Related Group Classification System: A systematic review

In health insurance, a reimbursement mechanism refers to a method of third-party repayment to offset the use of medical services and equipment. This systematic review aimed to identify challenges and adverse outcomes generated by the implementation of reimbursement mechanisms based on the diagnosis-related group (DRG) classification system. All articles published between 1983 and 2017 and indexed in various databases were reviewed. Of the 1,475 articles identified, 36 were relevant and were included in the analysis. Overall, the most frequent challenges were increased costs (especially for severe diseases and specialised services), a lack of adequate supervision and technical infrastructure and the complexity of the method. Adverse outcomes included reduced length of patient stay, early patient discharge, decreased admissions, increased re-admissions and reduced services. Moreover, DRG-based reimbursement mechanisms often resulted in the referral of patients to other institutions, thus transferring costs to other sectors.

Detecting hospital behaviors of up-coding on DRGs using Rasch model of continuous variables and online cloud computing in Taiwan

BACKGROUND

This work aims to apply data-detection algorithms to predict the possible deductions of reimbursement from Taiwan's Bureau of National Health Insurance (BNHI), and to design an online dashboard to send alerts and reminders to physicians after completing their patient discharge summaries.

METHODS

Reimbursement data for discharged patients were extracted from a Taiwan medical center in 2016. Using the Rasch model of continuous variables, we applied standardized residual analyses to 20 sets of norm-referenced diagnosis-related group (DRGs), each with 300 cases, and compared these to 194 cases with deducted records from the BNHI. We then examine whether the results of prediction using the Rasch model have a high probability associated with the deducted cases. Furthermore, an online dashboard was designed for use in the online monitoring of possible deductions on fee items in medical settings.

RESULTS

The results show that 1) the effects deducted by the NHRI can be predicted with an accuracy rate of 0.82 using the standardized residual approach of the Rasch model; 2) the accuracies for drug, medical material and examination fees are not associated among different years, and all of those areas under the ROC curve (AUC) are significantly greater than the randomized probability of 0.50; and 3) the online dashboard showing the possible deductions on fee items can be used by hospitals in the future.

CONCLUSION

The DRG-based comparisons in the possible deductions on medical fees, along with the algorithm based on Rasch modeling, can be a complementary tool in upgrading the efficiency and accuracy in processing medical fee applications in the discernable future.

Utilization rates of knee-arthroplasty in OECD countries

BACKGROUND

The number of knee arthroplasties and the prevalence of obesity are increasing exponentially. To date there have been no published reviews on utilization rates of knee arthroplasty in OECD countries.

METHODS

We analysed economic, medical and population data relating to knee arthroplasty surgeries performed in OECD countries. Gross domestic product (GDP), health expenditures, obesity prevalence, knee arthroplasty utilization rates and growth in knee arthroplasty rates per 100,000 population were assessed for total population, for patients aged 65 years and over, and patients aged 64 years and younger.

RESULTS

Obesity prevalence and utilization of knee arthroplasty have increased significantly in the past. The mean utilization rate of knee arthroplasty was 150 (22-235) cases per 100,000 total population in 2011. The strongest annual increase (7%) occurred in patients 64 years and under. Differences between individual countries can be explained by economic and medical patterns, with countries with higher medical expenditures and obesity prevalence having significantly higher utilization rates. Countries with lower utilization rates have significantly higher growth in utilization rates. The future demand for knee prostheses will increase x-fold by 2030, with exact rates dependant upon economic, social and medical factors.

CONCLUSION

We observed a 10-fold variation in the utilization of knee arthroplasty among OECD countries. A significant and strong correlation of GDP, health expenditures and obesity prevalence with utilization of knee arthroplasty was found. Patients aged 64 years and younger show a two-fold higher growth rate in knee arthroplasty compared to the older population. This trend could result in a four-fold demand for knee arthroplasty in OECD countries by 2030.

Financial analysis of revision knee surgery based on NHS tariffs and hospital costs: does it pay to provide a revision service?

Revision total knee arthroplasty (TKA) is a complex procedure which carries both a greater risk for patients and greater cost for the treating hospital than does a primary TKA. As well as the increased cost of peri-operative investigations, blood transfusions, surgical instrumentation, implants and operating time, there is a well-documented increased length of stay which accounts for most of the actual costs associated with surgery. We compared revision surgery for infection with revision for other causes (pain, instability, aseptic loosening and fracture). Complete clinical, demographic and economic data were obtained for 168 consecutive revision TKAs performed at a tertiary referral centre between 2005 and 2012. Revision surgery for infection was associated with a mean length of stay more than double that of aseptic cases (21.5 vs 9.5 days, p < 0.0001). The mean cost of a revision for infection was more than three times that of an aseptic revision (£30 011 (sd 4514) vs £9655 (sd 599.7), p < 0.0001). Current NHS tariffs do not fully reimburse the increased costs of providing a revision knee surgery service. Moreover, especially as greater costs are incurred for infected cases. These losses may adversely affect the provision of revision surgery in the NHS.

Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries

BACKGROUND

As part of the EuroDRG project, researchers from eleven countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Sweden, and Spain) compared how their Diagnosis-Related Groups (DRG) systems deal with cholecystectomy patients. The study aims to assist surgeons and national authorities to optimize their DRG systems.

METHODS

National or regional databases were used to identify hospital cases with a procedure of cholecystectomy. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardised case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained and compared to an index case.

RESULTS

European DRG systems vary widely: they classify cholecystectomy patients according to different sets of variables into diverging numbers of DRGs (between two DRGs in Austria and Poland to nine DRGs in England). The most complex DRG is valued at four times more resource intensive than the index case in Ireland but only 1.3 times more resource intensive than the index case in Austria.

CONCLUSION

Large variations in the classification of cholecystectomy patients raise concerns whether all systems rely on the most appropriate classification variables. Surgeons, hospital managers and national DRG authorities should consider how other countries' DRG systems classify cholecystectomy patients in order to optimize their DRG systems and to ensure fair and appropriate reimbursement.