Diagnosis-related groups for stroke in Europe: patient classification and hospital reimbursement in 11 countries

Comparison of diagnosis-related groups (DRG)-based hospital payment system design and implementation strategies in different countries: The case of ischemic stroke

Diagnosis-related groups (DRG) based hospital payment systems are gradually becoming the main mechanism for reimbursement of acute inpatient care. We reviewed the existing literature to ascertain the global use of DRG-based hospital payment systems, compared the similarities and differences of original DRG versions in ten countries, and used ischemic stroke as an example to ascertain the design and implementation strategies for various DRG systems. The current challenges with and direction for the development of DRG-based hospital payment systems are also analyzed. We found that the DRG systems vary greatly in countries in terms of their purpose, grouping, coding, and payment mechanisms although based on the same classification concept and that they have tended to develop differently in countries with different income classifications. In high-income countries, DRG-based hospital payment systems have gradually begun to weaken as a mainstream payment method, while in middle-income countries DRG-based hospital payment systems have attracted increasing attention and increased use. The example of ischemic stroke provides suggestions for mutual promotion of DRG-based hospital payment systems and disease management. How to determine the level of DRG payment incentives and improve system flexibility, balance payment goals and disease management goals, and integrate development with other payment methods are areas for future research on DRG-based hospital payment systems.

The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis

PURPOSE

The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA).

METHODS

A survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options.

RESULTS

Almost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects.

CONCLUSIONS

This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.

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.

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.

Can competition improve hospital quality of care? A difference-in-differences approach to evaluate the effect of increasing quality transparency on hospital quality

Public reporting on the quality of care is intended to guide patients to the provider with the highest quality and to stimulate a fair competition on quality. We apply a difference-in-differences design to test whether hospital quality has improved more in markets that are more competitive after the first public release of performance data in Germany in 2008. Panel data from 947 hospitals from 2006 to 2010 are used. Due to the high complexity of the treatment of stroke patients, we approximate general hospital quality by the 30-day risk-adjusted mortality rate for stroke treatment. Market structure is measured (comparatively) by the Herfindahl-Hirschman index (HHI) and by the number of hospitals in the relevant market. Predicted market shares based on exogenous variables only are used to compute the HHI to allow a causal interpretation of the reform effect. A homogenous positive effect of competition on quality of care is found. This effect is mainly driven by the response of non-profit hospitals that have a narrow range of services and private for-profit hospitals with a medium range of services. The results highlight the relevance of outcome transparency to enhance hospital quality competition.

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.

Cost Control of Treatment for Cerebrovascular Patients Using a Machine Learning Model in Western China

Background

Cerebrovascular disease has been the leading cause of death in China since 2017, and the control of medical expenses for these diseases is an urgent issue. Diagnosis-related groups (DRG) are increasingly being used to decrease the costs of healthcare worldwide. However, the classification variables and rules used vary from region to region. Of these variables, the question of whether the length of stay (LOS) should be used as a grouping variable is controversial.

Aim

To identify the factors influencing inpatient medical expenditure in cerebrovascular disease patients. The performance of two sets of classification rules, and the effects of the extent of control of unreasonable medical treatment, were compared, to investigate whether the classification variables should include LOS.

Methods

Data from 45,575 inpatients from a Healthcare Security Administration of a city in western China were used. Kruskal–Wallis H tests were used for single-factor analysis, and multiple linear stepwise regression was used to determine the main factors. A chi-squared automatic interaction detector (CHAID) algorithm was built as a decision tree model for grouping related data. The intensity of oversupply of service was controlled step by step from 10% to 100%, and the performance was calculated for each group.

Results

The average hospitalization cost was 1,284 US dollars, and the total was 51.17 million US dollars. Of this, 43.42 million were paid by the government, and 7.75 million were paid by individuals. Factors including gender, age, type of insurance, level of hospital, LOS, surgery, therapeutic outcomes, main concomitant disease, and hypertension significantly influenced inpatient expenditure (P < 0.05). Incorporating LOS, the patients were divided into seven DRG groups, while without LOS, the patients were divided into eight DRG groups. More clinical variables were needed to achieve good results without LOS. Of the two rule sets, smaller coefficient of variation (CV) and a lower upper limit for patient costs were found in the group including LOS. Using this type of economic control, 3.35 million US dollars could be saved in one year.

Research on diagnosis-related group grouping of inpatient medical expenditure in colorectal cancer patients based on a decision tree model

BACKGROUND

In 2018, the diagnosis-related groups prospective payment system (DRGs-PPS) was introduced in a trial operation in Beijing according to the requirements of medical and health reform. The implementation of the system requires that more than 300 disease types pay through the DRGs-PPS for medical insurance. Colorectal cancer (CRC), as a common malignant tumor with high prevalence in recent years, was among the 300 disease types.

AIM

To investigate the composition and factors related to inpatient medical expenditure in CRC patients based on disease DRGs, and to provide a basis for the rational economic control of hospitalization expenses for the diagnosis and treatment of CRC.

METHODS

The basic material and cost data for 1026 CRC inpatients in a Grade-A tertiary hospital in Beijing during 2014-2018 were collected using the medical record system. A variance analysis of the composition of medical expenditure was carried out, and a multivariate linear regression model was used to select influencing factors with the greatest statistical significance. A decision tree model based on the exhaustive χ² automatic interaction detector (E-CHAID) algorithm for DRG grouping was built by setting chosen factors as separation nodes, and the payment standard of each diagnostic group and upper limit cost were calculated. The correctness and rationality of the data were re-evaluated and verified by clinical practice.

RESULTS

The average hospital stay of the 1026 CRC patients investigated was 18.5 d, and the average hospitalization cost was 57872.4 RMB yuan. Factors including age, gender, length of hospital stay, diagnosis and treatment, as well as clinical operations had significant influence on inpatient expenditure (P < 0.05). By adopting age, diagnosis, treatment, and surgery as the grouping nodes, a decision tree model based on the E-CHAID algorithm was established, and the CRC patients were divided into 12 DRG cost groups. Among these 12 groups, the number of patients aged ≤ 67 years, and underwent surgery and chemotherapy or radiotherapy was largest; while patients aged > 67 years, and underwent surgery and chemotherapy or radiotherapy had the highest medical cost. In addition, the standard cost and upper limit cost in the 12 groups were calculated and re-evaluated.

CONCLUSION

It is important to strengthen the control over the use of drugs and management of the hospitalization process, surgery, diagnosis and treatment to reduce the economic burden on patients. Tailored adjustments to medical payment standards should be made according to the characteristics and treatment of disease types to improve the comprehensiveness and practicability of the DRGs-PPS.

Costs of clinical events in type 2 diabetes mellitus patients in the Netherlands: A systematic review

BACKGROUND

Type 2 diabetes mellitus (T2DM) is an established risk factor for cardiovascular and nephropathic events. In the Netherlands, prevalence of T2DM is expected to be as high as 8% by 2025. This will result in significant clinical and economic impact, highlighting the need for well-informed reimbursement decisions for new treatments. However, availability and consistent use of costing methodologies is limited.

OBJECTIVE

We aimed to systematically review recent costing data for T2DM-related cardiovascular and nephropathic events in the Netherlands.

METHODS

A systematic literature review in PubMed and Embase was conducted to identify available Dutch cost data for T2DM-related events, published in the last decade. Information extracted included costs, source, study population, and costing perspective. Finally, papers were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

Out of initially 570 papers, 36 agreed with the inclusion criteria. From these studies, 150 cost estimates for T2DM-related clinical events were identified. In total, 29 cost estimates were reported for myocardial infarction (range: €196-€27,038), 61 for stroke (€495-€54,678), fifteen for heart failure (€325-€16,561), 24 for renal failure (€2,438-€91,503), and seventeen for revascularisation (€3,000-€37,071). Only four estimates for transient ischaemic attack were available, ranging from €587 to €2,470. Adherence to CHEERS was generally high.

CONCLUSIONS

The most expensive clinical events were related to renal failure, while TIA was the least expensive event. Generally, there was substantial variation in reported cost estimates for T2DM-related events. Costing of clinical events should be improved and preferably standardised, as accurate and consistent results in economic models are desired.

Rehabilitative post-acute care for stroke patients delivered by per-diem payment system in different hospitalization paths: A Taiwan pilot study

Objective

To explore how post-acute care (PAC) for stroke patients delivered by per-diem payment system in varying hospitalization paths affects medical care utilization and functional status.

Design, setting and patients

A longitudinal prospective cohort study of 181 acute stroke patients in a southern Taiwan hospital and patients were separated into two groups: patients transferred from regional hospitals (group 1) and patients referred from medical centers (group 2).

Intervention

The intervention was a hospital based, function oriented, 3- to 12-weeks rehabilitative PAC intervention for patients with cerebrovascular diseases.

Measurements

Barthal Index, Functional Oral Intake Scale, Instrumental Activities of Daily Living Scale, EuroQoL Quality of Life Scale, and Berg Balance Scale.

Results

The average duration between day of stroke onset and day of admission to PAC ward was significantly (P < 0.001) shorter in group 1 (9.88 days) compared to group 2 (17.11 days). The average duration of PAC was also significantly (P < 0.01) shorter in group 1 (25.51 days) compared to group 2 (34.11 days). Finally, the average cost of PAC under per-diem payment was significantly lower (P < 0.01) in group 1 (US$2637) compared to group 2 (US$3450). Functional status significantly (P < 0.05) improved in patients who had received rehabilitative PAC. However, functional status did not significantly differ between the two groups.

Conclusions

The most effective way to reduce the costs of PAC for stroke patients is to minimize the duration of their hospital stay before transfer to rehabilitative PAC. Because it substantially reduces medical costs, rehabilitative PAC should be considered standard care for stroke patients.

Costs for stroke in Sweden 2009 and developments since 1997

OBJECTIVES

The aim of this study was to estimate direct and indirect excess costs attributable to stroke in Sweden in 2009 and to compare these with similar estimates from 1997.

METHODS

Data on first-ever stoke admissions in the first half of 2009 from the Swedish national stroke register (RS) were used for cost calculations and compared with results from 1997 also using RS data. A societal perspective was taken including the acute and follow-up phase, rehabilitation, stroke re-admissions, drugs, home- and residential care services for activities of daily life (ADL) support, and indirect costs for premature death and productivity losses (2009 prices). Survival was extrapolated to estimate the lifetime present value cost of stroke.

RESULTS

The societal lifetime present value cost for stroke in 2009 was €68,800 per patient (ADL support: 59 percent; productivity losses: 21 percent). Women had higher costs than men in all age groups as a result from greater need for ADL support. Patients treated at a stroke unit indicated low incremental cost per life-year gained compared with those who had not. The total lifetime cost increased between 1997 and 2009. Hospitalization costs per patient were stable, while long-term costs for home- and residential care services increased.

CONCLUSIONS

Changes in patient characteristics, longer expected survival, and possibly in the Swedish stroke care, have led to higher annual and lifetime costs per patient in 2009 compared with 1997. A comprehensive national stroke care performance register like RS may be suitable for health economic assessments.

How Well Do All Patient Refined-Diagnosis-Related Groups Explain Costs of Pediatric Cancer Chemotherapy Admissions in the United States?

PURPOSE

State-based Medicaid programs have begun using All Patient Refined-Diagnosis-Related Groups (APR-DRGs) to determine hospital reimbursement rates. Medicaid provides coverage for 45% of childhood cancer admissions. This study aimed to examine how well APR-DRGs reflect admission costs for childhood cancer chemotherapy to inform clinicians, hospitals, and policymakers in the wake of policy changes.

METHODS

We identified 25,613 chemotherapy admissions in the 2009 Kids' Inpatient Database. To determine how well APR-DRGs explain costs, we applied a hierarchic linear regression model of hospital costs, allowing for a variety of patient, hospital, and geographic confounders.

RESULTS

APR-DRGs proved to be the most important predictors of admission costs (P < .001), with costs increasing by DRG severity code. Diagnosis, age, and hospital characteristics also predicted costs above and beyond those explained by APR-DRGs. Compared with admissions for patients with acute lymphoblastic leukemia, costs of admissions for patients with acute myelomonocytic leukemia were 82% higher; non-Hodgkin lymphoma, 20% higher; Hodgkin lymphoma, 25% lower; and CNS tumors, 27% lower. Admissions for children who were 10 years of age or older cost 26% to 35% more than admissions for infants. Admissions to children's hospitals cost 46% more than admissions to other hospital types.

CONCLUSION

APR-DRGs developed for adults are applicable to childhood cancer chemotherapy but should be refined to account for cancer diagnosis and patient age. Possible policy and clinical management changes merit further study to address factors not captured by APR-DRGs.

Outcome, Use of Resources and Their Relationship in the Treatment of AMI, Stroke and Hip Fracture at European Hospitals

The aim of the present study was to compare the quality (survival), use of resources and their relationship in the treatment of three major conditions (acute myocardial infarction (AMI), stroke and hip fracture), in hospitals in five European countries (Finland, Hungary, Italy, Norway and Sweden). The comparison of quality and use of resources was based on hospital-level random effects models estimated from patient-level data. After examining quality and use of resources separately, we analysed whether a cost-quality trade-off existed between the hospitals. Our results showed notable differences between hospitals and countries in both survival and use of resources. Some evidence would support increasing the horizontal integration: higher degrees of concentration of regional AMI care were associated with lower use of resources. A positive relation between cost and quality in the care of AMI patients existed in Hungary and Finland. In the care of stroke and hip fracture, we found no evidence of a cost-quality trade-off. Thus, the cost-quality association was inconsistent and prevailed for certain treatments or patient groups, but not in all countries.

Heterogeneity of European DRG systems and potentials for a common EuroDRG system Comment on "Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries"

Diagnosis-Related Group (DRG) systems across Europe are very heterogeneous, in particular because of different classification variables and algorithms as well as costing methodologies. But, given the challenge of increasing patient mobility within Europe, health systems are forced to incorporate a common patient classification language in order to compare and identify similar patients e.g. for reimbursement purposes. Beside the national adoption of DRGs for a wide range of purposes (measuring hospital activity vs. paying hospitals), a common DRG system can serve as an international communication basis among health administrators and can reduce the national development efforts as it is demonstrated by the NordDRG consortium.

Cost-effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke in China

Background

Previous economic studies conducted in developed countries showed intravenous tissue-type plasminogen activator (tPA) is cost-effective for acute ischemic stroke. The present study aimed to determine the cost-effectiveness of tPA treatment in China, the largest developing country.

Methods

A combination of decision tree and Markov model was developed to determine the cost-effectiveness of tPA treatment versus non-tPA treatment within 4.5 hours after stroke onset. Outcomes and costs data were derived from the database of Thrombolysis Implementation and Monitor of acute ischemic Stroke in China (TIMS-China) study. Efficacy data were derived from a pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Costs and quality-adjusted life-years (QALYs) were compared in both short term (2 years) and long term (30 years). One-way and probabilistic sensitivity analyses were performed to test the robustness of the results.

Results

Comparing to non-tPA treatment, tPA treatment within 4.5 hours led to a short-term gain of 0.101 QALYs at an additional cost of CNY 9,520 (US$ 1,460), yielding an incremental cost-effectiveness ratio (ICER) of CNY 94,300 (US$ 14,500) per QALY gained in 2 years; and to a long-term gain of 0.422 QALYs at an additional cost of CNY 6,530 (US$ 1,000), yielding an ICER of CNY 15,500 (US$ 2,380) per QALY gained in 30 years. Probabilistic sensitivity analysis showed that tPA treatment is cost-effective in 98.7% of the simulations at a willingness-to-pay threshold of CNY 105,000 (US$ 16,200) per QALY.

Conclusions

Intravenous tPA treatment within 4.5 hours is highly cost-effective for acute ischemic strokes in China.

High total hospitalization cost but low cost of imaging studies in recurrent acute ischemic stroke patients

BACKGROUND

Due to the high risk and severity of recurrence after stroke attack, recurrence is a major reason contributing to the disease burden. This study aims to determine whether recurrence is a significant contributor of hospitalization cost in items for ischemic stroke patients.

METHODS

This study assessed acute ischemic stroke patients admitted to an academic medical center in 2003 through 2009. The t-test and Chi-square tests were used to compare first-ever and recurrent ischemic stroke groups in terms of total and categorized hospitalization cost, and multiple regression was performed to assess the influence of stroke recurrence.

RESULTS

Recurrent ischemic strokes were associated with higher total cost, but examination cost showed no difference between the two groups. The recurrent stroke group showed higher laboratory but lower imaging cost. Of imaging studies, there was no significant difference in computed tomography scan cost while the first-ever stroke group spent more on magnetic resonance imaging and sonography. Controlling for other influential factors, recurrence was discovered to be a significant factor in lowering examination cost.

CONCLUSIONS

The findings of stroke recurrence in lowering examination cost could be explained from two perspectives, different clinical patterns of healthcare utilization and patients' economic status in recurrent stroke.

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.