Acute Myocardial Infarction and DRGs
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.
DRGs are diagnosis-related groups of patients. They were originally developed in the 1970s by a group of researchers around Robert Fetter at Yale University in an attempt to define 'hospital products' and to enable the measurement of what hospital actually do. The basic idea of Fetter was to condense the confusingly large number of different (individual) patients treated by hospitals into a manageable number of (i) clinically meaningful and (ii) economically homogenous groups. Consequently, every DRG is characterized by certain clinical characteristics, e.g. certain diagnoses and/or procedures, and by a specific DRG weight, which is a measure of the average costs of treating patients falling into that DRG.
Diagnosis-related groups enable assessments of hospital activity, which are often called performance assessments, and they allow comparisons of costs, which otherwise would not be possible. For example, hospital (or departmental) activity can be assessed by calculating the casemix, i.e. the sum of all DRG weights 'produced' by a hospital (or department) during a given period of time; and treatment costs can be compared for similar patients—those falling into the same DRG. In addition, Medicare in the USA soon came to realize the potential of DRGs (as definitions of hospital products) for payment purposes, and introduced the first DRG-based hospital payment system in 1983.
Since then, DRGs have been adopted in most high-income countries around the world, albeit with different purposes. In some countries, e.g. Sweden and Finland, DRGs mainly serve as the basis for performance comparisons and benchmarking; in others, e.g. England, France, and Germany, DRGs are primarily used for hospital payment. Furthermore, considerable differences exist between countries in the combination of DRGs with other payment components, the methods used for the calculation of DRG weights, and the payment adjustments for structural characteristics of hospitals or for regional differences in costs. However, irrespective of the specific purpose of a DRG system, it is essential that the defined groups of patients are sufficiently homogenous in terms of treatment costs. Otherwise, performance comparisons on the basis of DRGs do not adequately control for differences between patients within the same groups; and reimbursement for a large number of patients is not appropriate; it can be either too high or too low.
Diagnosis-related groups are defined by patient classification systems (PCS)—i.e. DRG systems—which classify treatment cases into DRGs on the basis of classification variables such as diagnoses, procedures, and demographic characteristics. [Even though some systems do not define DRGs in the strict sense of the word (that is groups are not diagnosis related), this article uses the term DRGs to summarize all groups of patients defined by DRG systems or similar PCS.] To assure homogenous groups of patients, DRG systems need to consider the most important determinants of resource consumption as classification variables.
In many countries, professional medical associations, specialist experts or consultants formally participate in the process of selection, definition, and update of classification criteria via committees, expert hearings or consultations. Recently, Häkkinen et al. found that DRG-based hospital payment systems for acute myocardial infarction (AMI) patients could possibly be improved by incorporating additional disease-specific classification variables. Therefore, it is important that cardiologists are aware of how their respective patients are classified by their DRG systems in order to assess whether the classification variables adequately reflect differences in the complexity of treating different groups of patients using different techniques. Comparative analyses of how countries' DRG systems classify patients can help cardiologists to scrutinize national standards of classification against European equivalents in order to identify potential scope for improvement.
This study performs a comprehensive assessment of DRG systems across 11 European countries and has three main objectives: (i) to assess classification variables and algorithms used to group patients with AMI into DRGs; (ii) to compare variations in DRG weights; and (iii) to determine DRGs and hospital quasi prices for six standardized case vignettes of AMI patients with different combinations of demographic, diagnostic, and treatment variables.
Abstract and Introduction
Abstract
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.
Introduction
DRGs are diagnosis-related groups of patients. They were originally developed in the 1970s by a group of researchers around Robert Fetter at Yale University in an attempt to define 'hospital products' and to enable the measurement of what hospital actually do. The basic idea of Fetter was to condense the confusingly large number of different (individual) patients treated by hospitals into a manageable number of (i) clinically meaningful and (ii) economically homogenous groups. Consequently, every DRG is characterized by certain clinical characteristics, e.g. certain diagnoses and/or procedures, and by a specific DRG weight, which is a measure of the average costs of treating patients falling into that DRG.
Diagnosis-related groups enable assessments of hospital activity, which are often called performance assessments, and they allow comparisons of costs, which otherwise would not be possible. For example, hospital (or departmental) activity can be assessed by calculating the casemix, i.e. the sum of all DRG weights 'produced' by a hospital (or department) during a given period of time; and treatment costs can be compared for similar patients—those falling into the same DRG. In addition, Medicare in the USA soon came to realize the potential of DRGs (as definitions of hospital products) for payment purposes, and introduced the first DRG-based hospital payment system in 1983.
Since then, DRGs have been adopted in most high-income countries around the world, albeit with different purposes. In some countries, e.g. Sweden and Finland, DRGs mainly serve as the basis for performance comparisons and benchmarking; in others, e.g. England, France, and Germany, DRGs are primarily used for hospital payment. Furthermore, considerable differences exist between countries in the combination of DRGs with other payment components, the methods used for the calculation of DRG weights, and the payment adjustments for structural characteristics of hospitals or for regional differences in costs. However, irrespective of the specific purpose of a DRG system, it is essential that the defined groups of patients are sufficiently homogenous in terms of treatment costs. Otherwise, performance comparisons on the basis of DRGs do not adequately control for differences between patients within the same groups; and reimbursement for a large number of patients is not appropriate; it can be either too high or too low.
Diagnosis-related groups are defined by patient classification systems (PCS)—i.e. DRG systems—which classify treatment cases into DRGs on the basis of classification variables such as diagnoses, procedures, and demographic characteristics. [Even though some systems do not define DRGs in the strict sense of the word (that is groups are not diagnosis related), this article uses the term DRGs to summarize all groups of patients defined by DRG systems or similar PCS.] To assure homogenous groups of patients, DRG systems need to consider the most important determinants of resource consumption as classification variables.
In many countries, professional medical associations, specialist experts or consultants formally participate in the process of selection, definition, and update of classification criteria via committees, expert hearings or consultations. Recently, Häkkinen et al. found that DRG-based hospital payment systems for acute myocardial infarction (AMI) patients could possibly be improved by incorporating additional disease-specific classification variables. Therefore, it is important that cardiologists are aware of how their respective patients are classified by their DRG systems in order to assess whether the classification variables adequately reflect differences in the complexity of treating different groups of patients using different techniques. Comparative analyses of how countries' DRG systems classify patients can help cardiologists to scrutinize national standards of classification against European equivalents in order to identify potential scope for improvement.
This study performs a comprehensive assessment of DRG systems across 11 European countries and has three main objectives: (i) to assess classification variables and algorithms used to group patients with AMI into DRGs; (ii) to compare variations in DRG weights; and (iii) to determine DRGs and hospital quasi prices for six standardized case vignettes of AMI patients with different combinations of demographic, diagnostic, and treatment variables.