Prospective casemix-based funding, analysis and financial impact of cost outliers in all-patient refined diagnosis related groups in three Belgian general hospitals

Risk factors associated with prolonged hospital length-of-stay: 18-year retrospective study of hospitalizations in a tertiary healthcare center in Mexico

Background

Hospital length-of-Stay has been traditionally used as a surrogate to evaluate healthcare efficiency, as well as hospital resource utilization. Prolonged Length-of-stay (PLOS) is associated with increased mortality and other poor outcomes. Additionally, these patients represent a significant economic problem on public health systems and their families. We sought to describe and compare characteristics of patients with Normal hospital Length-of-Stay (NLOS) and PLOS to identify sociodemographic and disease-specific factors associated with PLOS in a tertiary care institution that attends adults with complicated diseases from all over Mexico.

Materials and methods

We conducted a retrospective analysis of hospital discharges from January 2000-December 2017 using institutional databases of medical records. We compared NLOS and PLOS using descriptive and inferential statistics. PLOS were defined as those above the 95^th percentile of length of hospitalization.

Results

We analyzed 85,904 hospitalizations (1,069,875 bed-days), of which 4,427 (5.1%) were PLOS (247,428 bed-days, 23.1% of total bed-days). Hematological neoplasms were the most common discharge diagnosis and surgery of the small bowel was the most common type of surgery. Younger age, male gender, a lower physician-to-patient ratio, emergency and weekend admissions, surgery, the number of comorbidities, residence outside Mexico City and lower socioeconomic status were associated with PLOS. Bone marrow transplant (OR 18.39 [95% CI 12.50–27.05, p<0.001), complex infectious diseases such as systemic mycoses and parasitoses (OR 4.65 [95% CI 3.40–6.63, p<0.001), and complex abdominal diseases such as intestinal fistula (OR 2.57 [95% CI 1.98–3.32) had the greatest risk for PLOS. Risk of mortality in patients with PLOS increased more than threefold (3.7% vs 13.3%, p<0.001).

Conclusions

We report some key sociodemographic and disease-specific differences in patients with PLOS. These could serve to develop a specific model of directed hospital healthcare for patients identified as in risk of PLOS.

Estimate of the Costs Caused by Adverse Effects in Hospitalised Patients Due to Hip Fracture: Design of the Study and Preliminary Results

Introduction: Hip fracture is a health problem that presents high morbidity and mortality, negatively influencing the patient’s quality of life and generating high costs. Structured analysis of quality indicators can facilitate decision-making, cost minimization, and improvement of the quality of care. Methods: We studied 1571 patients aged 70 years and over with the diagnosis of hip fracture at Hospital Universitario de la Ribera in the period between 1 January 2012 and 31 December 2016. Demographic, clinical, functional, and quality indicator variables were studied. An indirect analysis of the costs associated with adverse events arising during hospital admission was made. A tool based on the “Minimum Basic Data Set (CMBD)” was designed to monitor the influence of patient risk factors on the incidence of adverse effects (AE) and their associated costs. Results: The average age of the patients analysed was 84.15 years (SD 6.28), with a length of stay of 8.01 days (SD 3.32), a mean preoperative stay of 43.04 h (SD 30.81), and a mortality rate of 4.2%. Likewise, the percentage of patients with AE was 41.44%, and 11.01% of patients changed their cost as a consequence of these AEs suffered during hospital admission. The average cost of patients was €8752 (SD: 1,864) and the average cost increase in patients with adverse events was €2321 (SD: 3,164). Conclusions: Through the analysis of the main clinical characteristics and the indirect estimation of the complexity of the patients, a simple calculation of the average cost of the attention and its adverse events can be designed in patients who are admitted due to hip fracture. Additionally, this tool can fit the welfare quality indicators by severity and cost.

Determinants of the length of stay in stroke patients

OBJECTIVES

The study objective was to identify the factors that influence the length of stay (LOS) in hospital for stroke patients and to provide data for managing hospital costs by managing the LOS.

METHODS

This study used data from the Discharge Injury Survey of the Korea Centers for Disease Control and Prevention, which included 17,364 cases from 2005 to 2008.

RESULT

The LOS for stroke, cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage was 18.6, 15.0, 28.9, and 25.3 days, respectively. Patients who underwent surgery had longer LOS. When patients were divided based on whether they had surgery, there was a 2.4-time difference in the LOS for patients with subarachnoid hemorrhage, 2.0-time difference for patients with cerebral infarction, and 1.4-time difference for patients with intracerebral hemorrhage. The emergency route of admission and other diagnosis increased LOS, whereas hypertension and diabetic mellitus reduced LOS.

CONCLUSION

In the present rapidly changing hospital environments, hospitals approach an efficient policy for LOS, to maintain their revenues and quality of assessment. If LOS is used as the indicator of treatment expenses, there is a need to tackle factors that influence the LOS of stroke patients for each disease group who are divided based on whether surgery is performed or not for the proper management of the LOS.

What can we learn from international comparisons of costs by DRG?

OBJECTIVES

The objective of this study was to compare costs data by diagnosis related group (DRG) between Belgium and Switzerland. Our hypotheses were that differences between countries can probably be explained by methodological differences in cost calculations, by differences in medical practices and by differences in cost structures within the two countries.

METHODS

Classifications of DRG used in the two countries differ (AP-DRGs version 1.7 in Switzerland and APR-DRGs version 15.0 in Belgium). The first step of this study was to transform Belgian summaries into Swiss AP-DRGs. Belgian and Swiss data were calculated with a clinical costing methodology (full costing). Belgian and Swiss costs were converted into US$ PPP (purchasing power parity) in order to neutralize differences in purchasing power between countries.

RESULTS

The results of this study showed higher costs in Switzerland despite standardization of cost data according to PPP. The difference is not explained by the case-mix index because this was similar for inliers between the two countries. The length of stay (LOS) was also quite similar for inliers between the two countries. The case-mix index was, however, higher for high outliers in Belgium, as reflected in a higher LOS for these patients. Higher costs in Switzerland are thus probably explained mainly by the higher number of agency staff by service in this country or because of differences in medical practices.

CONCLUSIONS

It is possible to make international comparisons but only if there is standardization of the case-mix between countries and only if comparable accountancy methodologies are used. Harmonization of DRGs groups, nomenclature and accountancy is thus required.

Comparison of cost-weights scales methodologies in the perspective of a financing system based on pathologies

OBJECTIVES

Objectives of this article are to evaluate the possibility to create a CW scale by pathology on the basis of cost data from Belgian hospitals, to compare several methodologies to create this CW scale, and to evaluate the financial impact of a modification of the financing system on hospitals' income.

METHODS

CW scales were elaborated according to various methodologies in order to isolate the scale allowing the most adequate financing system, i.e. approaching the real costs as much as possible. Twelve scales were created. They vary according to the type of data used, according to DRGs and severities of illness included within the scale, and according to the variable used in order to isolate outliers.

RESULTS

For a similar case-mix, Hospitals H2 and H5 would see their financing increased through a prospective system based on the selected CW scale (No. 6). This modification would generate a reduction in financing going from -1 to -9% according to hospitals.

CONCLUSIONS

The cost database created made it possible to create a CW scale according to a technique which could constitute the first step of a PPS if advantages of a such financing system were established. In the Belgian context, it would be probably judicious to envisage regional databases allowing diversified methodological approaches whose results would be confronted, discussed, and coordinated at the federal level.