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

Hospitalization burden associated with anus and penis neoplasm in Spain (2016-2020)

In 2020, there were approximately 50,865 anal cancer cases and 36,068 penile cancer cases worldwide. HPV is considered the main causal agent for the development of anal cancer and one of the causal agents responsible for the development of penile cancer. The aim of this epidemiological, descriptive, retrospective study was to describe the burden of hospitalization associated with anal neoplasms in men and women and with penis neoplasms in men in Spain from 2016 to 2020. The National Hospital Data Surveillance System of the Ministry of Health, Conjunto Mínimo Básico de Datos, provided the discharge information used in this observational retrospective analysis. A total of 3,542 hospitalizations due to anal cancer and 4,270 hospitalizations due to penile cancer were found; For anal cancer, 57.4% of the hospitalizations occurred in men, and these hospitalizations were also associated with significantly younger mean age, longer hospital stays and greater costs than those in women. HIV was diagnosed in 11.19% of the patients with anal cancer and 1.74% of the patients with penile cancer. The hospitalization rate was 2.07 for men and 1.45 for women per 100,000 in anal cancer and of 4.38 per 100,000 men in penile cancer. The mortality rate was 0.21 for men and 0.12 for women per 100,000 in anal cancer and 0.31 per 100.000 men in penile cancer and the case-fatality rate was 10.07% in men and 8,26% in women for anal cancer and 7.04% in penile cancer. HIV diagnosis significantly increased the cost of hospitalization. For all the studied diagnoses, the median length of hospital stays and hospitalization cost increased with age. Our study offers relevant data on the burden of hospitalization for anal and penile cancer in Spain. This information can be useful for future assessment on the impact of preventive measures, such as screening or vaccination in Spain.

Optimizing Geriatric Venipuncture: A DRG-Compatible Team-Based Reengineering Strategy

Objective

This study evaluates a reengineered intervention aimed at improving the clinical management of intravenous indwelling needles in geriatric patients, focusing on cost-efficiency within the Diagnosis-Related Group (DRG) payment framework.

Methods

The intervention was assessed through a comparative study involving 387 elderly patients in the Geriatric Department of Xuanwu Hospital, between June 2021 and March 2022. The study contrasted outcomes between patients treated before and after implementing a new team-based management protocol in November 2021.

Results

Findings indicate enhanced first-attempt venipuncture success, reduced consumable costs, and decreased complication rates in the post-intervention group (P < 0.001), compared to controls.

Conclusion

The intervention demonstrates significant benefits in venipuncture efficiency, cost reduction, and patient safety, suggesting its potential for broader adoption in geriatric care.

The end of an era? Activity-based funding based on diagnosis-related groups: A review of payment reforms in the inpatient sector in 10 high-income countries

CONTEXT

Across the member countries of the Organisation for Economic Co-Operation and Development, policy makers are searching for new ways to pay hospitals for inpatient care to move from volume to value. This paper offers an overview of the latest reforms and their evidence to date.

METHODS

We reviewed reforms to DRG payment systems in 10 high-income countries: Australia, Austria, Canada (Ontario), Denmark, France, Germany, Norway, Poland, the United Kingdom (England), and the United States.

FINDINGS

We identified four reform trends among the observed countries, them being (1) reductions in the overall share of inpatient payments based on DRGs, (2) add-on payments for rural hospitals or their exclusion from the DRG system, (3) episode-based payments, which use one joint price to pay providers for all services delivered along a patient pathway, and (4) financial incentives to shift the delivery of care to less costly settings. Some countries have combined some or all of these measures with financial adjustments for quality of care. These reforms demonstrate a shift away from activity and efficiency towards a diversified set of targets, and mirror efforts to slow the rise in health expenditures while improving quality of care. Where evaluations are available, the evidence indicates mixed success in improving quality of care and reducing costs and expenditures.

Market Diffusion of Biosimilars in Off-Patent Biologic Drug Markets across Europe

Biologics are among the most expensive pharmaceuticals but have begun to lose their exclusivity rights over the past 15 years, offering the possibility for biosimilar competition. Therefore, we examine the market diffusion of biosimilars across Europe. Using revenues and sales data from IQVIA, we identified 12 biologic substances facing first biosimilar competition between 2014 and 2020 in 25 European countries. We investigated biosimilar market share depending on product and market characteristics with beta regression. Moreover, we compared market diffusion across countries using multilevel modelling. The average market share of biosimilars at first biosimilar entry was about seven percent in the retail and hospital market and grew to 34.69% and 38.29% after 16 quarters, respectively. Quarters since first biosimilar entry had a positive but decreasing effect on biosimilar market share (p<.001 for both markets). Quarterly growth ranged from 0.006 (Netherlands) to 0.026 (Slovakia) in the retail market and from 0.007 (Hungary) to 0.040 (United Kingdom) in the hospital market. The diffusion increased over time across all European markets, although at different rates. Biosimilar market share was higher in the hospital market. Compared to generics, diffusion of biosimilars is much slower. If policymakers desire to increase biosimilar diffusion, they should aim at policies that increase competition and use countries with the highest diffusion rates as benchmarks.

Burden of Hospitalizations Related to Pneumococcal Infection in Spain (2016-2020)

Pneumococcal infection strongly contributes to morbidity and mortality in Spain. A total of 253,899 hospitalizations related to pneumococcal infection occurred from 2016 to 2020. Fifty-eight percent were men, the mean age was 67 years old, and the average length of hospitalization was 12.72 days. The annual hospitalization rate was 10.84 hospitalizations per 10,000 population, increasing significantly with age, reaching 65.75 per 10,000 population in those aged >85 years. The hospitalization rates for pneumococcal pneumonia, sepsis, and meningitis were 2.91, 0.12, and 0.08 hospitalizations per 10,000, respectively, and reached the highest value in those aged >85 for pneumococcal pneumonia and sepsis, with 22.29 and 0.71 hospitalizations per 10,000, respectively, and in children up to 1 year old for pneumococcal meningitis, with 0.33 hospitalizations per 10,000. The total number of deaths during the study period was 35,716, with a case-fatality rate of 14.07%. For pneumococcal pneumonia, sepsis, and meningitis, the case-fatality rates were 8.47%, 23.71%, and 9.99%, respectively. The case-fatality rate increased with age and did not vary by sex. The annual cost of these hospitalizations was more than EUR 359 million. There is therefore a high burden of disease and mortality caused by pneumococcal infection in our country, especially in elderly individuals.

How Denmark, England, Estonia, France, Germany, and the USA Pay for Variable, Specialized and Low Volume Care: A Cross-country Comparison of In-patient Payment Systems

BACKGROUND

Diagnosis-related group (DRG)-based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, the United States [Medicare]).

METHODS

Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries.

RESULTS

Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the United States. Certain areas of care are almost always excluded (eg, certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers.

CONCLUSION

Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems.

All Patient Refined-Diagnosis Related Groups' (APR-DRGs) Severity of Illness and Risk of Mortality as predictors of in-hospital mortality

The aims of this study were to assess All-Patient Refined Diagnosis-Related Groups' (APR-DRG) Severity of Illness (SOI) and Risk of Mortality (ROM) as predictors of in-hospital mortality, comparing with Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) scores. We performed a retrospective observational study using mainland Portuguese public hospitalizations of adult patients from 2011 to 2016. Model discrimination (C-statistic/ area under the curve) and goodness-of-fit (R-squared) were calculated. Our results comprised 4,176,142 hospitalizations with 5.9% in-hospital deaths. Compared to the CCI and ECI models, the model considering SOI, age and sex showed a statistically significantly higher discrimination in 49.6% (132 out of 266) of APR-DRGs, while in the model with ROM that happened in 33.5% of APR-DRGs. Between these two models, SOI was the best performer for nearly 20% of APR-DRGs. Some particular APR-DRGs have showed good discrimination (e.g. related to burns, viral meningitis or specific transplants). In conclusion, SOI or ROM, combined with age and sex, perform better than more widely used comorbidity indices. Despite ROM being the only score specifically designed for in-hospital mortality prediction, SOI performed better. These findings can be helpful for hospital or organizational models benchmarking or epidemiological analysis.

Study of Hospitalization Costs in Patients with Cerebral Ischemia Based on E-CHAID Algorithm

Background. The aging of the population has led to a rapid increase in the prevalence of most neurological diseases between 1990 and 2016, with a growth rate of up to 117%, which has put enormous pressure on medical insurance funds. As one of the core diseases of disease diagnosis grouping, the hospitalization cost composition and grouping research of patients with cerebral ischemic disease can help to determine scientific payment standards and reduce the economic burden of patients. Aim. We aimed to understand the cost composition and influencing factors of hospitalized patients with cerebral ischemic diseases and to identify a reasonable cost grouping scheme. Methods. The data come from the homepage of medical records of inpatients with cerebral ischemia in a tertiary hospital in Sichuan Province from 2018 to 2020. After cleaning the data, a total of 5,204 pieces of data were obtained. Nonparametric tests and gamma regression models were used to explore the influencing factors of hospitalization costs. Taking the influencing factors as the predictor variables and the hospitalization cost as the target variable, the exhaustive Chi-squared automatic interaction detector (E-CHAID) algorithm was used to form the costs grouping, and the payment standard of the hospitalization cost for each group was determined. The rationality of cost grouping was evaluated by coefficient of variation (CV) and Kruskal–Wallis H test. Results. From 2018 to 2020, the average hospital stay of 5,204 inpatients with cerebral ischemic disease was 10.70 days, and the average hospitalization cost was 17,206.09 RMB yuan. Among the hospitalization costs, diagnosis costs and drug costs accounted for the highest proportion, accounting for 41.18% and 22.38%, respectively, in 2020. Gender, age, admission route, comorbidities and complications, super length of stay (>30 days), and discharge mode had significant effects on hospitalization costs (P < 0.05). Patients were divided into 10 cost groups, and the grouping nodes included comorbidities and complications, discharge mode, age, gender, and admission route. The CV of 9 of the 10 cost groups is less than or equal to 1. The Kruskal–Wallis H test showed that the difference between groups was statistically significant (P < 0.05). Conclusion. The cost grouping of patients with cerebral ischemic diseases based on the E-CHAID algorithm is reasonable. This study examined the effects of super length of stay (>30 days), comorbidities and complications, and age on hospitalization cost in patients with cerebral ischemic disease. This study can provide a theoretical basis for advancing the China Healthcare Security Diagnosis Related Groups (CHS-DRG) grouping program and medical expense payment, thereby reducing the disease burden of patients.

[Integrated care concepts and multidisciplinary process chains in a radiological context]

Modern patient-centered and cost-efficient care concepts in hospitals require the mapping of multidisciplinary process chains into clinical pathways. Clinical decision support systems and operations research methods use algorithms to classify patients into homogeneous groups and to model a complete clinical pathway for scheduling individual procedures. An improvement of the economic situation of the care facility can be achieved through improved resource utilization, reduced patient waiting times and a shortening of the length of stay. The interdisciplinary use of centrally stored interoperable information and comprehensive care management via information technology (IT) services lay the foundation for the dissolution of traditional IT system architectures in medicine and the development of flexibly integrable modern system platforms. New IT approaches such as the semantically standardized definition of procedures and resource properties, the use of clinical decision support systems and the use of service-oriented system architectures form the basis for the deep integration of radiology services into comprehensive interdisciplinary care concepts.

The process of estimating the cost of surgery: Providing a practical framework for surgeons

Over the last decades, health care costs have been increasing at an alarming, exponential rate which is considered unsustainable. Surgical care utilizes one-third of health care costs. Estimating, evaluating, and understanding the cost of surgery is a vital step towards cost management and reduction. Current cost estimation studies and cost-effectiveness studies have vast disparities in their methodology, with published costs of Operating Room varying from as low as $7 and as high as $113 per minute. Costs in surgery are distinguished as direct and indirect. Allocation of direct costs involves identification, measurement, and valuation processes. Allocation of indirect costs involves the allocation of capital and overhead costs and of indirect department costs. Annualised capital costs and overhead hospital costs are then allocated to surgery by either the cost-centre allocation or the activity-based allocation frameworks. Indirect department costs are allocated to a specific surgery by weighted service allocation or hourly rate allocation or inpatient day allocation, or marginal markup allocation. The growing societal, financial and political pressure for cost reduction has brought cost analysis to the forefront of healthcare discussions. Thus, we believe that almost every single surgeon will eventually enter the field of healthcare economics by necessity. This review aims to provide surgeons with a practical framework for engaging in cost estimation studies.

Economic evidence with respect to cost-effectiveness of the transitional care model among geriatric patients discharged from hospital to home: a systematic review

BACKGROUND

The German hospital-to-home discharge management of geriatric patients has long been criticized. The implementation of the American Transitional Care Model (TCM) could help to reduce readmissions and costs. The objective of this review was to check the scientific evidence of the cost-effectiveness of the TCM.

METHODS

A systematic literature search in six databases for the time period of 26 years was conducted. The studies had to meet all pre-defined inclusion criteria. The data extraction is based on a criteria chart from literature. The methodological quality was assessed using the tools of the National Heart, Lung, and Blood Institute as well as the Consensus Health Economic Criteria list. The results transferability to German health care system was explained based on the criteria from the literature.

RESULTS

Three American studies met all criteria. They showed partial cost analyses but no full economic analyses. It could be assumed that the economic effect of the TCM changes over time. The costs of a care coordinator could not be determined because few detailed information was reported. The TCM may have negative consequences for hospitals. The results are not transferable to Germany.

CONCLUSION

There is no scientific evidence for the cost-effectiveness of the defined TCM. The optimal TCM duration still needs to be clarified. A detailed overview with units and prices and an additional consideration of the hospital perspective could help to make the information more transparent when deciding about the TCM implementation. A full economic analysis under German conditions or for similar European countries is necessary.

Managerial workarounds in three European DRG systems

Purpose

Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy.

Design/methodology/approach

We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews ( N  = 154), analysis of policy documents ( N  = 111) and an action learning set, began in 2010–12, with additional data collection from key informants and administrative documents continuing in 2018–19 to supplement and update our findings.

Findings

Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load ‘ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed ‘floor' volume.

Research limitations/implications

Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the ‘managerial workaround’ still further.

Practical implications

In the case of DRGs, the managerial workarounds were instances of ‘constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the ‘managerial workaround'.

Social implications

Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection.

Originality/value

So far as we are aware, no other study presents and tests the concept of a ‘managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

Burden of severe bronchiolitis in children up to 2 years of age in Spain from 2012 to 2017

Bronchiolitis represents a heavy burden of disease in children under 2 years of age in our society due to the high infectivity of the Respiratory Syncytial Virus [RSV] and the vulnerability of the youngest children.

The objective of this retrospective epidemiological study was to show the burden of severe bronchiolitis in Spain through population-based estimates of hospitalizations due to bronchiolitis in children up to 24 months old during a 6-year period (2012–2017).

A total of 100,115 cases of bronchiolitis required hospitalization in Spain from 2012 to 2017. Most cases of bronchiolitis that required hospitalization were in infants under 3 months of age. The hospitalization rate for bronchiolitis for children under 1 year of age was 3,838.27 per 100,000 healthy children. During the 6-year study period, a total of 82 deaths due to bronchiolitis were reported among hospitalized infants. Among these deaths, more than 50% were in patients younger than 3 months of age. The annual average cost to the National Health Care System was €58 M, with a mean hospitalization cost of €3,512 per case.

Describing Serbian Hospital Activity Using Australian Refined Diagnosis Related Groups: A Case Study in Vojvodina Province

Introduction

AR-DRG system for classification hospital episodes was implemented in Serbia to improve efficiency and transparency in the health system.

Methods

L3H3, IQR, and 10th-95th percentile methods were used to identify outlier episodes in the classification. Classification efficiency and within-group homogeneity were measured by an adjusted reduction in variance (R2) and a coefficient of variation (CV).

Results

There were 246,131 hospital episodes with a total 1,651,913 bed days from 14 hospitals. All episodes were classified into 652 groups of which 441 had CV lower than 100%. "Medical groups" accounted for 51% of groups and for 72% of episodes. Chemotherapy and vaginal delivery were the highest volume groups, with 5% and 4% of total episodes. Major diagnostic category 6 (MDC 6, Diseases of the digestive system) was the highest volume MDC, accounting for 11% of episodes. "Day-cases" and "prolonged hospitalisation" accounted for 21% and 3% of episodes, respectively. The average length of stay varied from 5.6 to 8.2 days. Adjusted R2 was 0.3 for untrimmed data. Trimming by L3H3, IQR, and 10th-95th percentile method improved the value of adjusted R2 to 0.61, 0.49, and 0.51, identifying 24%, 7%, and 7% of total cases as outliers, respectively. Mental diseases (MDC 19) remained the lowest adjusted R2 in untrimmed and trimmed datasets.

Conclusion

A long length of stay and a small percentage of "day-cases" characterized hospital activity in Vojvodina. Trimming methods significantly improved DRG efficiency. Future studies should consider cost data.

Costs structure of the inpatient ischemic stroke treatment using an exact costing method

Objectives

Most stroke care expenses are inhospital costs. Given the previously reported inaccuracy of conventional costing, the purpose of this study was to provide an accurate analysis of inpatient costs of stroke care in an acute care hospital.

Materials and methods

We used activity-based costing (ABC) for calculating the costs of ischemic stroke patients. We collected the activity data at the Helsinki University Central Hospital. Persons involved in patient care logged their activities on survey forms for one week. The costs of activities were calculated based on information about salaries, material prices, and other costs obtained from hospital accounting data. We calculated costs per inpatient days and episodes, analyzed cost structure, made a distinction in cost for stroke subtypes according to the Oxford and TOAST classification schemes, and compared cost per inpatient episode with the diagnoses-related group (DRG) -price of the hospital.

Results

The sample comprised 196 inpatient days of 41 patients. By using the ABC, the mean and median costs of an inpatient day were 346 € and 268 €, and of an inpatient episode 3322 € and 2573 €, respectively. Average costs differed considerably by stroke subtype. The first inpatient day was the most expensive. Working time costs comprised 63% of the average inpatient day cost, with nursing constituting the largest proportion. The mean cost of an inpatient episode was 21% lower with ABC than with DRG pricing.

Conclusion

We demonstrate that there are differences in cost estimates depending on the methods used. ABC revealed differences among patients having the same diagnosis. The cost of an episode was lower than the DRG price of the hospital. Choosing an optimal costing method is essential for both reimbursements of hospitals and health policy decision-making.

Changepoint analysis of gestational age and birth weight: proposing a refinement of Diagnosis Related Groups

BACKGROUND

Although the complexity and length of treatment is connected to the newborn's maturity and birth weight, most case-mix grouping schemes classify newborns by birth weight alone. The objective of this study was to determine whether the definition of thresholds based on a changepoint analysis of variability of birth weight and gestational age contributes to a more homogenous classification.

METHODS

This retrospective observational study was conducted at a Tertiary Care Center with Level III Neonatal Intensive Care and included neonate cases from 2016 through 2018. The institutional database of routinely collected health data was used. The design of this cohort study was explorative. The cases were categorized according to WHO gestational age classes and SwissDRG birth weight classes. A changepoint analysis was conducted. Cut-off values were determined.

RESULTS

When grouping the cases according to the calculated changepoints, the variability within the groups with regard to case related costs could be reduced. A refined grouping was achieved especially with cases of >2500 g birth weight. An adjusted Grouping Grid for practical purposes was developed.

CONCLUSIONS

A novel method of classification of newborn cases by changepoint analysis was developed, providing the possibility to assign costs or outcome indicators to grouping mechanisms by gestational age and birth weight combined.

Direct and lost productivity costs associated with avoidable hospital admissions

Background

Hospitalizations for ambulatory care sensitive conditions are commonly used to evaluate primary health care performance, as the hospital admission could be avoided if care was timely and adequate. Previous evidence indicates that avoidable hospitalizations carry a substantial direct financial burden in some countries. However, no attention has been given to the economic burden on society they represent. The aim of this study is to estimate the direct and lost productivity costs of avoidable hospital admissions in Portugal.

Methods

Hospitalizations occurring in Portugal in 2015 were analyzed. Avoidable hospitalizations were defined and their associated costs and years of potential life lost were calculated. Direct costs were obtained using official hospitalization prices. For lost productivity, there were estimated costs for absenteeism and premature death. Costs were analyzed by components, by conditions and by variations on estimation parameters.

Results

The total estimated cost associated with avoidable hospital admissions was €250 million (€2515 per hospitalization), corresponding to 6% of the total budget of public hospitals in Portugal. These hospitalizations led to 109,641 years of potential life lost. Bacterial pneumonia, congestive heart failure and urinary tract infection accounted for 77% of the overall costs. Nearly 82% of avoidable hospitalizations were in patients aged 65 years or older, therefore did not account for the lost productivity costs. Nearly 84% of the total cost comes from the direct cost of the hospitalization. Lost productivity costs are estimated to be around €40 million.

Conclusion

The age distribution of avoidable hospitalizations had a significant effect on costs components. Not only did hospital admissions have a substantial direct economic impact, they also imposed a considerable economic burden on society. Substantial financial resources could potentially be saved if the country reduced avoidable hospitalizations.

Acute rule-out of non-ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART score assessment and a single point-of-care troponin: rationale and design of the ARTICA randomised trial

INTRODUCTION

Because of the lack of prehospital protocols to rule out a non-ST-segment elevation acute coronary syndrome (NSTE-ACS), patients with chest pain are often transferred to the emergency department (ED) for thorough evaluation. However, in low-risk patients, an ACS is rarely found, resulting in unnecessary healthcare consumption. Using the HEART (History, ECG, Age, Risk factors and Troponin) score, low-risk patients are easily identified. When a point-of-care (POC) troponin measurement is included in the HEART score, an ACS can adequately be ruled out in low-risk patients in the prehospital setting. However, it remains unclear whether a prehospital rule-out strategy using the HEART score and a POC troponin measurement in patients with suspected NSTE-ACS is cost-effective.

METHODS AND ANALYSIS

The ARTICA trial is a randomised trial in which the primary objective is to investigate the cost-effectiveness after 30 days of an early rule-out strategy for low-risk patients suspected of a NSTE-ACS, using a modified HEART score including a POC troponin T measurement. Patients are included by ambulance paramedics and 1:1 randomised for (1) presentation at the ED (control group) or (2) POC troponin T measurement (intervention group) and transfer of the care to the general practitioner in case of a low troponin T value. In total, 866 patients will be included. Follow-up will be performed after 30 days, 6 months and 12 months.

ETHICS AND DISSEMINATION

This trial has been accepted by the Medical Research Ethics Committee region Arnhem-Nijmegen. The results of this trial will be disseminated in one main paper and in additional papers with subgroup analyses.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NL7148).

Changing payment instruments and the utilisation of new medical technologies

This paper empirically investigates the impact of additional reimbursement instruments on the diffusion of new technologies in inpatient care. Using 2010-2014 German panel data on hospital level for every patient undergoing coronary angioplasty, this study examines the utilisation of drug-eluting balloon catheters (DEB) over time while additional payment instruments changed. Hypothesising that the utilisation of DEB increased abruptly when a new reimbursement instrument came into force, we estimate a fixed effects regression comparing years with a change and years where the reimbursement instrument remained the same. The model is adjusted for patient age and severity of the disease. The utilisation of DEB increased from 8407 in 2010 to 19,065 in 2014. Hospitals used significantly more DEB when an additional payment instrument changed compared to years when it remained the same. The increase was roughly twice as large. In short, hospitals are incentivised to utilise new technologies if the reimbursement changes to an instrument that is designed in a more reliable way, e.g. including less bureaucracy or guaranteeing fixed prices.

Sharing Frailty-related information in perioperative care: an analysis from a temporal perspective

BACKGROUND

Especially patients older than 65 years undergoing surgery are prone to develop frailty-related complications that may go far beyond the index hospitalization (e.g., cognitive impairment following postoperative delirium). However, aging-relevant information are currently not fully integrated into hospitals' perioperative processes.

METHODS

We introduce a temporal perspective, which focuses on the social construction of time, to better understand existing barriers to the exchange of frailty-related data, targeting complexity research. Our chosen context is perioperative care provided by a tertiary hospital in Germany that has implemented a special track for patients over 65 years old undergoing elective surgery. The research followed a participatory modelling approach between domain and modelling experts with the goal of creating a feedback loop model of the relevant system relationships and dynamics.

RESULTS

The results of the study show how disparate temporal regimes, understood as frameworks for organizing actions in the light of time constraints, time pressure, and deadlines, across different clinical, ambulant, and geriatric care sectors create disincentives to cooperate in frailty-related data exchanges. Moreover, we find that shifting baselines, meaning continuous increases in cost and time pressure in individual sectors, may unintentionally reinforce - rather than discourage - disparate temporal regimes.

CONCLUSIONS

Together, these results may (1) help to increase awareness of the importance of frailty-related data exchanges, and (2) impel efforts aiming to transform treatment processes to go beyond sectoral boundaries, taking into account the potential benefits for frail patients arising from integrated care processes using information technology.

Regional regulators in health care service under quality competition: A game theoretical model

In several countries, health care services are provided by public and/or private subjects, and they are reimbursed by the government, on the basis of regulated prices (in most countries, diagnosis-related group). Providers take prices as given and compete on quality to attract patients. In some countries, regulated prices differ across regions. This paper focuses on the interdependence between regional regulators within a country: It studies how price setters of different regions interact, in a simple but realistic framework. Specifically, we model a circular city as divided in two administrative regions. Each region has two providers and one regulator, who sets the local price. Patients are mobile and make their choice on the basis of provider location and service quality. Interregional mobility occurs in the presence of asymmetries in providers' cost efficiency, regulated prices, and service quality. We show that the optimal regulated price is higher in the region with the more efficient providers; we also show that decentralisation of price regulation implies higher expenditure but higher patients' welfare.

Hospital financing of ischaemic stroke: determinants of funding and usefulness of DRG subcategories based on severity of illness

Background

Several Western and Arab countries, as well as over 30 States in the US are using the “All-Patient Refined Diagnosis-Related Groups” (APR-DRGs) with four severity-of-illness (SOI) subcategories as a model for hospital funding. The aim of this study is to verify whether this is an adequate model for funding stroke hospital admissions, and to explore which risk factors and complications may influence the amount of funding.

Methods

A bottom-up analysis of 2496 ischaemic stroke admissions in Belgium compares detailed in-hospital resource use (including length of stay, imaging, lab tests, visits and drugs) per SOI category and calculates total hospitalisation costs. A second analysis examines the relationship between the type and location of the index stroke, medical risk factors, patient characteristics, comorbidities and in-hospital complications on the one hand, and the funding level received by the hospital on the other hand. This dataset included 2513 hospitalisations reporting on 35,195 secondary diagnosis codes, all medically coded with the International Classification of Disease (ICD-9).

Results

Total costs per admission increased by SOI (€3710–€16,735), with severe patients costing proportionally more in bed days (86%), and milder patients costing more in medical imaging (24%). In all resource categories (bed days, medications, visits and imaging and laboratory tests), the absolute utilisation rate was higher among severe patients, but also showed more variability.

SOI 1–2 was associated with vague, non-specific stroke-related ICD-9 codes as primary diagnosis (71–81% of hospitalisations). 24% hospitalisations had, in addition to the primary diagnosis, other stroke-related codes as secondary diagnoses. Presence of lung infections, intracranial bleeding, severe kidney disease, and do-not-resuscitate status were each associated with extreme SOI (p < 0.0001).

Conclusions

APR-DRG with SOI subclassification is a useful funding model as it clusters stroke patients in homogenous groups in terms of resource use. The data on medical care utilisation can be used with unit costs from other countries with similar healthcare set-ups to 1) assess stroke-related hospital funding versus actual costs; 2) inform economic models on stroke prevention and treatment. The data on diagnosis codes can be used to 3) understand which factors influence hospital funding; 4) raise awareness about medical coding practices.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3134-6) contains supplementary material, which is available to authorized users.

Economic Analysis of the Reduction of Blood Transfusions during Surgical Procedures While Continuous Hemoglobin Monitoring Is Used

Background: Two million transfusions are performed in Spain every year. These come at a high economic price for the health system, increasing the morbidity and mortality rates. The way of obtaining the hemoglobin concentration value is via invasive and intermittent methods, the results of which take time to obtain. The drawbacks of this method mean that some transfusions are unnecessary. New continuous noninvasive hemoglobin measurement technology can save unnecessary transfusions. Methods: A prospective study was carried out with a historical control of two homogeneous groups. The control group used the traditional hemoglobin measurement methodology. The experimental group used the new continuous hemoglobin measurement technology. The difference was analyzed by comparing the transfused units of the groups. The economic savings was calculated by multiplying the cost of a transfusion by the difference in units, taking into account measurement costs. Results: The percentage of patients needing a transfusion decreased by 7.4%, and the number of transfused units per patient by 12.56%. Economic savings per patient were €20.59. At the national level, savings were estimated to be 13,500 transfusions (€1.736 million). Conclusions: Constant monitoring of the hemoglobin level significantly reduces the need for blood transfusions. By using this new measurement technology, health care facilities can significantly reduce costs and improve care quality.

Diagnosis related group grouping study of senile cataract patients based on E-CHAID algorithm

AIM

To figure out the contributed factors of the hospitalization expenses of senile cataract patients (HECP) and build up an area-specified senile cataract diagnosis related group (DRG) of Shanghai thereby formulating the reference range of HECP and providing scientific basis for the fair use and supervision of the health care insurance fund.

METHODS

The data was collected from the first page of the medical records of 22 097 hospitalized patients from tertiary hospitals in Shanghai from 2010 to 2012 whose major diagnosis were senile cataract. Firstly, we analyzed the influence factors of HECP using univariate and multivariate analysis. DRG grouping was conducted according to the exhaustive Chi-squared automatic interaction detector (E-CHAID) model, using HECP as target variable. Finally we evaluated the grouping results using non-parametric test such as Kruskal-Wallis H test, RIV, CV, etc.

RESULTS

The 6 DRGs were established as well as criterion of HECP, using age, sex, type of surgery and whether complications/comorbidities occurred as the key variables of classification node of senile cataract cases.

CONCLUSION

The grouping of senile cataract cases based on E-CHAID algorithm is reasonable. And the criterion of HECP based on DRG can provide a feasible way of management in the fair use and supervision of medical insurance fund.

Analysis of economic and social costs of adverse events associated with blood transfusions in Spain

OBJECTIVE

To calculate, for the first time, the direct and social costs of transfusion-related adverse events in order to include them in the National Healthcare System's budget, calculation and studies. In Spain more than 1,500 patients yearly are diagnosed with such adverse events.

METHOD

Blood transfusion-related adverse events recorded yearly in Spanish haemovigilance reports were studied retrospectively (2010-2015). The adverse events were coded according to the classification of Diagnosis-Related Groups. The direct healthcare costs were obtained from public information sources. The productivity loss (social cost) associated with adverse events was calculated using the human capital and hedonic salary methodologies.

RESULTS

In 2015, 1,588 patients had adverse events that resulted in direct health care costs (4,568,914€) and social costs due to hospitalization (200,724€). Three adverse reactions resulted in patient death (at a social cost of 1,364,805€). In total, the cost of blood transfusion-related adverse events was 6,134,443€ in Spain. For the period 2010-2015: the trends show a reduction in the total amount of transfusions (2 vs. 1.91M€; -4.4%). The number of adverse events increased (822 vs. 1,588; +93%), as well as their related direct healthcare cost (3.22 vs. 4.57M€; +42%) and the social cost of hospitalization (110 vs 200M€; +83%). Mortality costs decreased (2.65 vs. 1.36M€; -48%).

DISCUSSION

This is the first time that the costs of post-transfusion adverse events have been calculated in Spain. These new figures and trends should be taken into consideration in any cost-effectiveness study or trial of new surgical techniques or sanitary policies that influence blood transfusion activities.

How should hospital reimbursement be refined to support concentration of complex care services?

The English National Health Service is promoting concentration of the treatment of patients with relatively rare and complex conditions into a limited number of specialist centres. If these patients are more costly to treat, the prospective payment system based on Healthcare Resource Groups (HRGs) may need refinement because these centres will be financially disadvantaged. To assess the funding implications of this concentration policy, we estimate the cost differentials associated with caring for patients that receive complex care and examine the extent to which complex care services are concentrated across hospitals and HRGs. We estimate random effects models using patient-level activity and cost data for all patients admitted to English hospitals during the 2013/14 financial year and construct measures of the concentration of complex services. Payments for complex care services need to be adjusted if they have large cost differentials and if provision is concentrated within a few hospitals. Payments can be adjusted either by refining HRGs or making top-up payments to HRG prices. HRG refinement is preferred to top-payments the greater the concentration of services among HRGs.

Cost Accounting in Public Hospitals in Poland

The aim of this article is to assess the cost accounting solutions that are used currently in Polish hospitals. The evaluation covered three main areas that require cost data—management, external reporting and pricing of health services (performed by a regulatory body). The study concerned the costing model that was obligatory for Polish public hospitals in the years 1998–2011 (top-down micro-costing model) and has not yet been replaced by another solution. Different research methods have been used for each of the areas under research, inter alia surveys, direct interviews and case study methods.

Empirical results indicate a limited usefulness of the researched costing model in all of the evaluated areas: management, financial reporting and pricing. First, the costing model is used moderately only for the most important management areas, such as planning, control and operational decision making. Second, it does not include the specifics of diagnosis-related groups (DRGs) (basic pricing object) and therefore does not allow for accurate determination of their costs. Third, due to lack of the complex costing methodology the model is used in an unstructured and incoherent manner.

Estimation of a physician practice cost function

OBJECTIVE

The goal of the present paper is to provide evidence on the behavior of physician practice cost functions.

DATA SOURCES

Our study is based on the data of 3686 physician practices in Germany for the years 2006 to 2008.

STUDY DESIGN

We apply a translog functional form and include a comprehensive set of variables that have not been previously used in this context. A system of four equations using three-stage least squares is estimated.

PRINCIPAL FINDINGS

We find that a higher degree of specialization leads to a decrease in costs, whereas quality certification increases costs. Costs of group practices are higher than of solo practices. The latter finding can be explained by the existence of indivisibilities of expensive technical equipment. Smaller practices do not reach the critical mass to invest in certain technologies, which leads to differences in the type of health care services provided by different practice types.

CONCLUSIONS

This is the first study to use physician practices as the unit of observation and to consider the endogenous character of physician input. Our results suggest that identifying factors that influence physician practice costs is important for providing evidence-based physician payment systems and to enable decision-makers to set incentives effectively.

Economic evaluation of chronic lymphocytic leukemia from a hospital management perspective

OBJECTIVES

Treatment of chronic lymphocytic leukemia (CLL) is currently undergoing dramatic changes. We analyzed economic risks in hospitalized patients with CLL from a management perspective.

METHODS

One hundred and twelve patients with CLL hospitalized in 2013 and 2014 at the University Hospital of Cologne were analyzed. To assess profit margins (PMs) per case, diagnosis-related group (DRG) reimbursement data were merged with an internal cost accounting scheme depending on age, prognostic factors, and DRG key performance indicators.

RESULTS

In 112 patients, 284 cases coded by 19 different DRG with strongly fluctuating cost revenue ratios were found with an overall negative PM of €137 147. The DRG R61H was identified as the one most commonly coded (174 cases, 61.3%) with a deficit per case of €814. Subanalysis demonstrated that the payments were not cost covering due to excessive length of stay and staff costs. Significant differences in PM per case concerning age, length of stay and number of operation and procedure key (OPS) codes (P < 0.05) were found.

CONCLUSION

In our research-driven tertiary care hospital, inpatient treatment of patients with CLL is not cost covering. This analysis demonstrates the need for novel care/reimbursement structures in CLL. From a hospital management perspective, cost revenue controlling is crucial to avoid major economic risks.

Measuring the Burden of Hospitalization in Patients with Parkinson´s Disease in Spain

INTRODUCTION

This epidemiological survey estimates the hospitalization burden related to Parkinson´s Disease in Spain.

METHODS

This observational retrospective survey was performed by reviewing data from the National Surveillance System for Hospital Data, which includes more than 98% of Spanish hospitals. All hospitalizations of patients with Parkinson´s disease that were reported from 1997-2012 were analyzed. Codes were selected using the 9th International Classification of Diseases: ICD-9-CM: 332.0.

RESULTS

A total of 438,513 hospital discharges of patients with Parkinson´s Disease were reported during the study period. The annual hospitalization rate was 64.2 cases per 100,000. The average length of hospital stay was 10 days. The trend for the annual hospitalization rate differed significantly depending on whether Parkinson´s disease was the main cause of hospitalization (n = 23,086, 1.14% annual increase) or was not the main cause of hospitalization (n = 415,427, 15.37% annual increase). The overall case-fatality rate among hospitalized patients was 10%. The case fatality rate among patient´s hospitalized with Parkinson´s disease as the main cause of hospitalization was 2.5%. The hospitalization rate and case-fatality rate significantly increased with age. The primary causes of hospitalization when Parkinson´s disease was not coded as the main cause of hospitalization were as follows: respiratory system diseases (24%), circulatory system diseases (19%), injuries and poisoning, including fractures (12%), diseases of the digestive system (10%) and neoplasms (5%). The annual average cost for National Health Care System was € 120 M, with a mean hospitalization cost of €4,378.

CONCLUSIONS

Parkinson´s disease poses a significant health threat in Spain, particularly in the elderly. While hospitalizations due to Parkinson´s Disease are relatively stable over time, the number of patients presenting with Parkinson´s disease as an important comorbidity has increased dramatically. Medical staff must be specifically trained to treat the particular needs of hospitalized patients suffering from Parkinson´s disease as an important comorbidity.

Risk of hospitalization due to pneumococcal disease in adults in Spain. The CORIENNE study

Pneumococcal disease causes a high burden of disease in adults, leading to high rates of hospitalization, especially in the elderly. All hospital discharges for pneumococcal disease and pneumococcal pneumonia among adults over 18 y of age reported in first diagnostic position in 2011 (January 1, 2011 through December 31, 2011) were obtained. A total of 10,861 hospital discharges due to pneumococcal disease were reported in adults in Spain in 2011 with an annual incidence of hospitalization of 0.285 (CI 95%: 0.280-0.291) per 1,000 population over 18 y old. Case-fatality rate was 8%. Estimated cost of these hospitalisations in 2011 was more than 57 million €. Pneumococcal pneumonia accounted for the 92% of the hospital discharges All the chronic condition studied: asplenia, chronic respiratory disease, chronic heart disease, chronic renal disease, Diabetes Mellitus and immunosuppression, increased the risk of hospitalization in patients with pneumococcal pneumonia, especially in those aged 18-64 y old. Case-fatality rate among adult patients hospitalized with at least one underlying condition was significantly higher than among patients without comorbidities. Our results identified asplenia, chronic respiratory disease, chronic heart disease, chronic renal disease, chronic liver disease, Diabetes Mellitus and immunosuppression as risk groups for hospitalization. Older adults, immunocompromised patients and immunocompetent patients with underlying conditions could benefit from vaccination.

The Expenditures for Academic Inpatient Care of Inflammatory Bowel Disease Patients Are Almost Double Compared with Average Academic Gastroenterology and Hepatology Cases and Not Fully Recovered by Diagnosis-Related Group (DRG) Proceeds

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC) challenge economies worldwide. Detailed health economic data of DRG based academic inpatient care for inflammatory bowel disease (IBD) patients in Europe is unavailable.

METHODS

IBD was identified through ICD-10 K50 and K51 code groups. We took an actual costing approach, compared expenditures to G-DRG and non-DRG proceeds and performed detailed cost center and type accounting to identify coverage determinants.

RESULTS

Of all 3093 hospitalized cases at our department, 164 were CD and 157 UC inpatients in 2012. On average, they were 44.1 (CD 44.9 UC 43.3 all 58) years old, stayed 10.1 (CD 11.8 UC 8.4 vs. all 8) days, carried 5.8 (CD 6.4 UC 5.2 vs. all 6.8) secondary diagnoses, received 7.4 (CD 7.7 UC 7 vs. all 6.2) procedures, had a higher cost weight (CD 2.8 UC 2.4 vs. all 1.6) and required more intense nursing. Their care was more costly (means: total cost IBD 8477€ CD 9051€ UC 7903€ vs. all 5078€). However, expenditures were not fully recovered by DRG proceeds (means: IBD 7413€, CD 8441€, UC 6384€ vs all 4758€). We discovered substantial disease specific mismatches in cost centers and types and identified the medical ward personnel and materials budgets to be most imbalanced. Non-DRG proceeds were almost double (IBD 16.1% vs. all 8.2%), but did not balance deficits at total coverage analysis, that found medications (antimicrobials, biologics and blood products), medical materials (mostly endoscopy items) to contribute most to the deficit.

CONCLUSIONS

DRGs challenge sophisticated IBD care.

The effect of physicians’ financial incentives on the diagnosis related group-based prospective reimbursement scheme in Taiwan

This study examines whether the implementation of a Physician Compensation Program (PCP) improved departmental performance in a large private not-for-profit hospital’s performance after it implemented the Taiwan Diagnosis Related Group-based (Tw-DRG) prospective reimbursement scheme. Because hospitals in Taiwan are structurally similar to staff-model HMOs, the effects of PCPs on hospital performance under the Tw-DRG scheme in Taiwan may have implications for staff-model HMOs. The data sample contains 624 monthly observations of the 26 departments in the case hospital for the period 2009–2010. Of the 26 departments, 18 have implemented the Tw-DRG scheme and are classified as the Tw-DRG group; and the other eight departments are classified as the non-Tw-DRG group. Since the introduction of the scheme, the physicians in both groups have been paid under the PCP. Overall, the results show that the case hospital’s performance deteriorated after the scheme was implemented. The findings imply that conflicts arise in hospitals where some departments have implemented the Tw-DRG scheme that encourages hospitals to reduce the utilization of medical resources, while physicians in those departments are still paid under the PCP and are, therefore, motivated to expand medical services without trying to reduce costs. As a result, the Tw-DRG scheme may fail or only have a limited effect. This study also provides evidence that physicians’ behavior affects their clinical performance, especially under a strict cost containment payment policy. Taiwan’s experience provides a good opportunity to evaluate, simultaneously, the effects of cost containment mechanisms and physicians’ incentive plans within a staff-model context.

Respiratory Syncytial Virus Bronchiolitis in Children up to 5 Years of Age in Spain: Epidemiology and Comorbidities: An Observational Study

This epidemiological survey in Spain estimates the burden of respiratory syncytial virus (RSV) infection in children up to 5 year of age during a 15-year period (1997-2011). Observational retrospective survey was conducted by reviewing data of the National Surveillance System for Hospital Data, including >98% of Spanish hospitals. All hospitalizations related to RSV infection for children up to 5 years, reported during 1997-2011 period, were analyzed. Codes were selected by using the International Classification of Diseases 9th Clinical Modification 466.0-466.19, 480.1, and 079.6. A total of 326,175 and 286,007 hospital discharges for children up to 5 and 2 years of age were reported during the study period. The annual incidence was 1072 and 2413 patients per 100,000, respectively. The average length of hospital stay was 5.7 (standard deviation 8.2) days. Four hundred forty-six deaths were reported; of those, 403 occurred in children <2 years and 355 (80%) occurred in children <12 months of age. Hospitalization and mortality rates were significantly higher in boys and decrease significantly with age. The higher rate of hospitalization and mortality rates were found in the first year of life. Annual average cost for National Health Care System was € 47 M with a mean hospitalization cost of €2162. The average length of hospitalization and costs were significantly higher in high-risk children. RSV infections in children up to 5 year of age still pose a significant health threat in Spain, especially in the infants. The development of preventive, diagnostic, and therapeutic guidelines focused in children with comorbidities may help reduce the hospital and economic burden of the disease.

The role of hospital payments in the adoption of new medical technologies: an international survey of current practice

This study examined the role of prospective payment systems in the adoption of new medical technologies across different countries. A literature review was conducted to provide background for the study and guide development of a survey instrument. The survey was disseminated to hospital payment systems experts in 15 jurisdictions. Fifty-one surveys were disseminated, with 34 returned. The surveys returned covered 14 of the 15 jurisdictions invited to participate. The majority (71%) of countries update the patient classification system and/or payment tariffs on an annual basis to try to account for new technologies. Use of short-term separate or supplementary payments for new technologies occurs in 79% of countries to ensure adequate funding and facilitate adoption. A minority (43%) of countries use evidence of therapeutic benefit and/or costs to determine or update payment tariffs, although it is somewhat more common in establishing short-term payments. The main barrier to using evidence is uncertain or unavailable clinical evidence. Almost three-fourths of respondents believed diagnosis-related group systems incentivize or deter technology adoption, depending on the particular circumstances. Improvements are needed, such as enhanced strategies for evidence generation and linking evidence of value to payments, national and international collaboration and training to improve existing practice, and flexible timelines for short-term payments. Importantly, additional research is needed to understand how different payment policies impact technology uptake as well as quality of care and costs.

Hospital financing: calculating inpatient capital costs in Germany with a comparative view on operating costs and the English costing scheme

OBJECTIVES

The paper analyzes the German inpatient capital costing scheme by assessing its cost module calculation. The costing scheme represents the first separated national calculation of performance-oriented capital cost lump sums per DRG.

METHODS

The three steps in the costing scheme are reviewed and assessed: (1) accrual of capital costs; (2) cost-center and cost category accounting; (3) data processing for capital cost modules. The assessment of each step is based on its level of transparency and efficiency. A comparative view on operating costing and the English costing scheme is given.

RESULTS

Advantages of the scheme are low participation hurdles, low calculation effort for G-DRG calculation participants, highly differentiated cost-center/cost category separation, and advanced patient-based resource allocation. The exclusion of relevant capital costs, nontransparent resource allocation, and unclear capital cost modules, limit the managerial relevance and transparency of the capital costing scheme.

CONCLUSIONS

The scheme generates the technical premises for a change from dual financing by insurances (operating costs) and state (capital costs) to a single financing source. The new capital costing scheme will intensify the discussion on how to solve the current investment backlog in Germany and can assist regulators in other countries with the introduction of accurate capital costing.

A European inventory of common electronic health record data elements for clinical trial feasibility

Background

Clinical studies are a necessity for new medications and therapies. Many studies, however, struggle to meet their recruitment numbers in time or have problems in meeting them at all. With increasing numbers of electronic health records (EHRs) in hospitals, huge databanks emerge that could be utilized to support research. The Innovative Medicine Initiative (IMI) funded project ‘Electronic Health Records for Clinical Research’ (EHR4CR) created a standardized and homogenous inventory of data elements to support research by utilizing EHRs. Our aim was to develop a Data Inventory that contains elements required for site feasibility analysis.

Methods

The Data Inventory was created in an iterative, consensus driven approach, by a group of up to 30 people consisting of pharmaceutical experts and informatics specialists. An initial list was subsequently expanded by data elements of simplified eligibility criteria from clinical trial protocols. Each element was manually reviewed by pharmaceutical experts and standard definitions were identified and added. To verify their availability, data exports of the source systems at eleven university hospitals throughout Europe were conducted and evaluated.

Results

The Data Inventory consists of 75 data elements that, on the one hand are frequently used in clinical studies, and on the other hand are available in European EHR systems. Rankings of data elements were created from the results of the data exports. In addition a sub-list was created with 21 data elements that were separated from the Data Inventory because of their low usage in routine documentation.

Conclusion

The data elements in the Data Inventory were identified with the knowledge of domain experts from pharmaceutical companies. Currently, not all information that is frequently used in site feasibility is documented in routine patient care.

Explaining length of stay variation of episodes of care in the Netherlands

OBJECTIVES

Diagnosis Related Group (DRG) systems aim to classify patients into mutually exclusive groups of patients, with the patients in each group having the same expected length of stay (LOS). We examined the ability of current classification variables to explain LOS variation between DRG-like Diagnosis Treatment Combination (DBC)s for ten episodes of care in the Netherlands, including breast cancer, stroke and inguinal hernia repair. Additionally, we assessed the predictive ability of some other classification variables.

METHODS

For each episode of care, the relevant DBC codes of all hospitalizations in 2008 were identified and all available determinants that may serve as classification variables were acquired from the national database. Ordinary least squares regression was used to examine the predictive ability of these classification variables.

RESULTS

The current classification variables are not sufficiently distinct to classify patients into mutually exclusive groups of patients. ICU admissions and hospital type may serve as valuable classification variables. Additionally, episode-specific variables may improve the Dutch grouping algorithm.

CONCLUSIONS

Although it may not be feasible in the short term, grouping algorithms would benefit greatly from the introduction of classification variables tailored to the needs of specific episodes of care. A first step would be to focus on 'general' classification variables meaningful for specific episodes of care.

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

PURPOSE

Researchers from 11 countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their Diagnosis-Related Group (DRG) systems deal with knee replacement cases. The study aims to assist knee surgeons and national authorities to optimize the grouping algorithm of their DRG systems.

METHODS

National or regional databases were used to identify hospital cases treated with a procedure of knee replacement. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97 % of cases. Five standardized case scenarios were defined and quasi-prices according to national DRG-based hospital payment systems ascertained.

RESULTS

Grouping algorithms for knee replacement vary widely across countries: they classify cases according to different variables (between one and five classification variables) into diverging numbers of DRGs (between one and five DRGs). Even the most expensive DRGs generally have a cost index below 2.00, implying that grouping algorithms do not adequately account for cases that are more than twice as costly as the index DRG. Quasi-prices for the most complex case vary between euro 4,920 in Estonia and euro 14,081 in Spain.

CONCLUSIONS

Most European DRG systems were observed to insufficiently consider the most important determinants of resource consumption. Several countries' DRG system might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities. Ultimately, this would contribute to assuring adequate performance comparisons and fair hospital reimbursement on the basis of DRGs.

Acute myocardial infarction and diagnosis-related groups: patient classification and hospital reimbursement in 11 European countries

AIMS

As part of the diagnosis related groups in Europe (EuroDRG) project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their DRG systems deal with patients admitted to hospital for acute myocardial infarction (AMI). The study aims to assist cardiologists and national authorities to optimize their DRG systems.

METHODS AND RESULTS

National or regional databases were used to identify hospital cases with a primary diagnosis of AMI. Diagnosis-related group classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems vary widely: they classify AMI patients according to different sets of variables into diverging numbers of DRGs (between 4 DRGs in Estonia and 16 DRGs in France). The most complex DRG is valued 11 times more resource intensive than an index case in Estonia but only 1.38 times more resource intensive than an index case in England. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only €420 in Poland but to €7930 in Ireland.

CONCLUSIONS

Large variation exists in the classification of AMI patients across Europe. Cardiologists and national DRG authorities should consider how other countries' DRG systems classify AMI patients in order to identify potential scope for improvement and to ensure fair and appropriate reimbursement.

Hospitalizations from pandemic Influenza [A(H1N1)pdm09] infections among type 1 and 2 diabetes patients in Spain

OBJECTIVES

To describe and analyze the clinical characteristics and outcomes for all patients with diabetes who were hospitalized with laboratory-confirmed A(H1N1)pdm09 infections in Spain during 2009.

METHODS

Observational retrospective study using data collected by the Spanish National Hospital Discharge Database. We selected all admissions with diagnosis ICD-9-CM code 488·1 [A(H1N1)pdm09]. Discharges were grouped as follows: no diabetes, Type1 and Type 2 diabetes. Underlying medical conditions and risk factors included all those that constitute an indication for annual influenza vaccination, pregnancy, and obesity. The outcome variables analyzed were in-hospital case fatality risk, length of hospital stay, and costs.

RESULTS

The total number of persons hospitalized with A(H1N1)pdm09 was 11,499. Of those, 97 suffered Type 1 and 936 Type 2, giving an overall prevalence of diabetes of 9%. The most common underlying medical condition among Type 2 subjects was obesity (26·8%), and for Type 1 renal disease (10·3%). In-hospital mortality was 2·1% among Type 1 patients, 3·8% among Type 2 patients, and 2·3% among non-diabetics; after multivariate analysis, diabetes was not a factor independently associated with dying during hospitalization for A(H1N1)pdm09. Independent factors increasing the risk of death among diabetic patients included age (OR 1·03; 95% CI1·01-1·05), hematological disorders (OR 3·49; 95% CI, 1·46-8·37), and obesity (OR 1·88; 95% CI1·07-3·92).

CONCLUSIONS

Among individuals hospitalized in Spain with A(H1N1)pdm09 infections, the age-specific prevalence of diabetes was higher than the general population in most age groups. The results of multivariate analysis suggest that possibly concomitant conditions such as obesity increase the risk of dying from the infection, but not diabetes itself.

Cost of illness and economic burden of chronic lymphocytic leukemia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is a slowly progressing but fatal disease that imposes a high economic burden on sickness funds and society. The objective of this study was to analyze and compare the direct and indirect costs of CLL in Germany from the perspective of the sickness funds and society and analyze the burden of the disease.

METHODS

Using a database of 7.6 million enrolled individuals, we identified 4198 CLL patients in 2007 and 2008. The costs attributable to CLL were estimated using a case-control design with a randomly selected control group of 150 individuals per combination of age and sex. We used the bootstrap approach to estimate uncertainties in costs estimated. We employed generalized estimating equation regression models and count data models to test for differences in costs and healthcare utilization.

RESULTS

The cost attributable to CLL for each prevalent case amounts to €4946 from the payer's perspective and €7910 from a societal perspective. Inpatient hospital stays and pharmaceuticals are the main cost drivers of the disease. The economic burden of disease in Germany was estimated to be approximately €201 million per year for the sickness funds and €322 million for society.

CONCLUSIONS

Compared with common diseases, such as diabetes or COPD, the economic burden of CLL is considerably lower. However, the cost of treatment per case is about twice as high as the cost per case for these common diseases, even though treatment is only performed in the later stages of CLL. With new healthcare technologies, the aging population, and the increasing incidence of the disease, it is likely that the economic burden of the disease will continue to grow.

Has incentive payment improved venous thrombo-embolism risk assessment and treatment of hospital in-patients?

This paper focuses on financial incentives rewarding successful implementation of guidelines in the UK National Health Service (NHS). In particular, it assesses the implementation of National Institute for Health and Clinical Excellence (NICE) venous thrombo-embolism (VTE) guidance in 2010 on the risk assessment and secondary prevention of VTE in hospital in-patients and the financial incentives driving successful implementation introduced by the Commissioning for Quality and Innovation for Payment Framework (CQUIN) for 2010-2011. We systematically compared the implementation of evidence-based national guidance on VTE prevention across two specialities (general medicine and orthopaedics) in four hospital sites in the greater South West of England by auditing and evaluating VTE prevention activity for 2009 (i.e. before the 2010 NICE guideline) and late 2010 (almost a year after the guideline was published). Analysis of VTE prevention activity reported in 816 randomly selected orthopaedic and general medical in-patient medical records was complemented by a qualitative study into the practical responses to revised national guidance. This paper's contribution to knowledge is to suggest that by financially rewarding the implementation of national guidance on VTE prevention, paradoxes and contradictions have become apparent between the 'payment by volume system' of Healthcare Resource Groups and the 'payment by results' system of CQUIN.

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

OBJECTIVES

The study compares how Diagnosis-Related Group (DRG) based hospital payment systems in eleven European countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) deal with women giving birth in hospitals. It aims to assist gynaecologists and national authorities in optimizing their DRG systems.

METHODS

National or regional databases were used to identify childbirth cases. DRG grouping algorithms and indicators of resource consumption were compared for those DRGs which account for at least 1% of all childbirth cases in the respective database. Five standardized case vignettes were defined and quasi prices (i.e. administrative prices or tariffs) of hospital deliveries according to national DRG-based hospital payment systems were ascertained.

RESULTS

European DRG systems classify childbirth cases according to different sets of variables (between one and eight variables) into diverging numbers of DRGs (between three and eight DRGs). The most complex DRG is valued 3.5 times more resource intensive than an index case in Ireland but only 1.1 times more resource intensive than an index case in The Netherlands. Comparisons of quasi prices for the vignettes show that hypothetical payments for the most complex case amount to only € 479 in Poland but to € 5532 in Ireland.

CONCLUSIONS

Differences in the classification of hospital childbirth cases into DRGs raise concerns whether European systems rely on the most appropriate classification variables. Physicians, hospitals and national DRG authorities should consider how other countries' DRG systems classify cases to optimize their system and to ensure fair and appropriate reimbursement.

Introduction of DRG-based reimbursement in inpatient psychosomatics--an examination of cost homogeneity and cost predictors in the treatment of patients with eating disorders

OBJECTIVE

Various western countries are focusing on the introduction of reimbursement based on diagnosis-related groups (DRG) in inpatient mental health. The aim of this study was to analyze if psychosomatic inpatients treated for eating disorders could be reimbursed by a common per diem rate.

METHODS

Inclusion criteria for patient selection (n=256) were (1) a main diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder-related obesity (OB), (2) minimum length of hospital stay of 2 days, (3) and treatment at Charité Universitaetsmedizin Berlin, Germany during the years 2006-2009. Cost calculation was executed from the hospital's perspective, mainly using micro-costing. Generalized linear models with Gamma error distribution and log link function were estimated with per diem costs as dependent variable, clinical and patient variables as well as treatment year as independent variables.

RESULTS

Mean costs/case for AN amounted to 5,251€, 95% CI [4407-6095], for BN to 3,265€, 95% CI [2921-3610] and for OB to 3,722€, 95% CI [4407-6095]. Mean costs/day over all patients amounted to 208€, 95% CI [198-218]. The diagnosis AN predicted higher costs in comparison to OB (p=.0009). A co-morbid personality disorder (p=.0442), every one-unit increase in BMI in OB patients (p=.0256), every one-unit decrease in BMI in AN patients (p=.0002) and every additional life year in BN patients (p=.0455) predicted increased costs.

CONCLUSION

We see a need for refinements to take into account considerable variations in treatment costs between patients with eating disorders due to diagnosis, BMI, co-morbid personality disorder and age.

Improving patient-level costing in the English and the German 'DRG' system

OBJECTIVES

The purpose of this paper is to develop ways to improve patient-level cost apportioning (PLCA) in the English and German inpatient 'DRG' cost accounting systems, to support regulators in improving costing schemes, and to give clinicians and hospital management sophisticated tools to measure and link their management.

METHODS

The paper analyzes and evaluates the PLCA step in the cost accounting schemes of both countries according to the impact on the key aspects of DRG introduction: transparency and efficiency. The goal is to generate a best available PLCA standard with enhanced accuracy and managerial relevance, the main requirements of cost accounting.

RESULTS

A best available PLCA standard in 'DRG' cost accounting uses: (1) the cost-matrix from the German system; (2) a third axis in this matrix, representing service-lines or clinical pathways; (3) a scoring system for key cost drivers with the long-term objective of time-driven activity-based costing and (4) a point of delivery separation.

CONCLUSION

Both systems have elements that the other system can learn from. By combining their strengths, regulators are supported in enhancing PLCA systems, improving the accuracy of national reimbursement and the managerial relevance of inpatient cost accounting systems, in order to reduce costs in health care.