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Mona Heurgren Head of Unit Unit for Development of Quality and Efficiency Studies

Improvement of the NordDRG systems ability to describe performance - a new logic for comorbidity and/or complications. Mona Heurgren Head of Unit Unit for Development of Quality and Efficiency Studies The National Board of Health and Welfare Sweden. Agenda.

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Mona Heurgren Head of Unit Unit for Development of Quality and Efficiency Studies

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  1. Improvement of the NordDRG systems ability to describe performance - a new logic for comorbidity and/or complications Mona Heurgren Head of Unit Unit for Development of Quality and Efficiency Studies The National Board of Health and Welfare Sweden

  2. Agenda • The scoop and benefits of casemix adjustments • Background and acknowledgements of the project • Aims and Method • Results • Areas of use • Discussion about the impact of a new system

  3. The scoop of casemix adjustments • The idea of casemix is to adjust for differences in severity of illness, medical practice or risk of mortality in a defined group of patients/inhabitants or other populations • The current NordDRG system adjusts primly for severity of illness and medical practice per case for patients treated in hospitals • The ACG (Adjusted Clinical Groups)-system adjusts for severity of illness in a defined population per patient and year • The IR-system (3M) adjusts for both severity of illness, medical practise and risk of mortality per case for patients treated in hospitals

  4. Why improve NordDRGs ability to adjust for casemix? • To improve how to describe performance with DRGs (ex to be used for productivity and efficiency studies) • A better adjustment for casemix when comparing hospital performance in health care • To improve the analysis of differences in casemix in hospitals • To improve how to describe processes and medical pathways • To develop better prospective payment systems and budgeting tools • To achieve a higher acceptance for DRGs in the professional community

  5. Background • During the last decade there has been an ongoing discussion about the need to improve the NordDRGs ability to describe patients comorbidity and/or complications. • The last years the coding of diagnoses and procedures in Swedish hospitals has improved significantly. • Several countries have already done the development work and changes (US, Canada, Australia).

  6. Acknowledgements • The project is financed by the National Board of Health and Welfare (Socialstyrelsen) by grants from the Government • The project group represents a mix of different competences. Economist, physicians, statistician and medical secretary. • Per Sjöli Project leader • Mona Heurgren Project owner • Mats Fernström Medical advisor • Ralph Dahlgren Medical advisor • Gunnar Henriksson Medical advisor • Liselotte Säll Secretary • Åke Karlsson Statistician • Anders Jacobsson Statistician • Martti Virtanen Technical and medical advisor

  7. The aim of the project • To develop a new logic within the NordDRG-system for comorbidity and/or complications (CC-logic) • To produce logic tables and a software product for acceptance tests in primly Sweden and Finland • The project will be finished in June 2010 • Acceptance tests during 2010-2011

  8. Method • To learn from others; a totally new method would require both more data and resources • Solution • To use the method of the Federal government DRG-office (CMS) in the US, the MS (Medicare Severity) -DRG system • The logic can be found at the internet • Development work • Translate ICD9CM to ICD10 diagnoses • Verify secondary diagnoses significance with volume and cost data (National Patient registry and Case costing database) • Manually grouping and validation of the new logic from both a medical, statistical and economical perspective with respect to the criteria's for changing the NordDRG system • Production of definition tables, databases and a grouper to NordDRG-CC

  9. Criteria's for changing DRGs • The new group should embrace at least 3% of the original volume • The average cost difference between the new group and the old group should at least be 20% • The variation (cv) in the new groups should decrease with at least 5% • The overall performance in the system should improve or the change must at least not have a negative impact

  10. The Scoop of NordDRG-CC • Concerns inpatient care only - Exceptions: Newborns, Rehabilitation, Psychiatric care • The main change is a new level in the logic for comorbidity and/or complications (CC-level): • No CC (cases with no significant comorbidity and/or complications) • CC (cases with moderate comorbidity and/or complications) • MCC (cases with major comorbidity and/or complications)

  11. NordDRG-CC, preliminary results • 790 DRGs • 188 uncomplicated groups • 464 CC or CC/MCC groups • 138 unique MCC groups Approximatly 250 more groups than the current grouper for inpatient care.

  12. NordDRG 2010 NordDRG-CC Stroke, NO CC, 014b No: 7 235 Cost:40 737 SEK CV:70% Stroke, NO CC,014b No:7 859 Cost:42 871 SEK CV:75% Stroke 014 No:15 400 Cost:52 377 SEK CV:78% Stroke, CC, 014CC No:6 635 Cost:56 654 SEK CV:70% Stroke, CC, 014a No: 7 541 Kost:62 284 SEK CV:75% Stroke, MCC, 014MCC No: 1 530 Cost:88 876 SEK CV:73% STROKE – Development of groping logic Base DRG

  13. Drg Drgtxt Weight A011 Tumours in the nervous system, without CC/MCC 0,8570 A011CC Tumours in the nervous system, with CC 1,2446 A011MCC Tumours in the nervous system, with MCC 1,9631 A012 Degenerative disorders in the nervous system, without CC/MCC 0,8848 A012MCC Degenerative disorders in the nervous system, with CC/MCC 1,8501 A014B Specific vascular disorders in the brain excl TIA, without CC/MCC 1,0565 A014BCC Specific vascular disorders in the brain excl TIA, with CC 1,4036 A014BMCC Specific vascular disorders in the brain excl TIA, with MCC 2,2348 A015 TIA and occlusion of precerebral arteries, without CC/MCC 0,4858 A015MCC TIA and occlusion of precerebral arteries, with CC/MCC 0,8667 A019 Disorders in brain nerves and peripheral nerves, without CC/MCC 0,6012 A019CC Disorders in brain nerves and peripheral nerves, with CC 0,8903 A019MCC Disorders in brain nerves and peripheral nerves, with MCC 1,0419 NordDRG-CC – example of weights • Weight 1.0 – average in the cost database (trimmed)

  14. More results NordDRG-CC • The overall performance of the NordDRG system has improved: • R2 (explanatory value) increases by 10% • The cost variation (cv) within the DRGs has decreased (especially for uncomplicated groups) • The cost weights are - Decreasing for uncomplicated groups (No CC) - Increasing for CC and MCC groups; Cases in MCC-groups are on average: • 200% more expensive than uncomplicated groups • 35% more expensive than CC-groups • The weights for deceased patients and acute patients are increasing in general

  15. Uncomplicated Ceasarian Section

  16. Conclusions • The NordDRG-CC grouper: • Describes casemix better than the current grouper • Contributes to reduced variation in the majority of the DRGs • Improves the performance of the whole system • The coding in Sweden appear to be sufficient • Relatively simple logic, not to much changes to current logic • The grouper software will be ready this summer • Will require more maintenance work?

  17. Areas of use • The NordDRG-CC is developed with the aim to improve how to describe performance with DRGs • Better adjustments of casemix for Benchmarking purposes and in productivity and efficiency studies are the main reasons for improvement work • The NordDRG-CC can also be used for improvement of reimbursement and budgeting in clinics/hospitals/regions/countries • Other effects on quality • Acceptance of DRGs among the professionals increases • Monitoring and explain variances in clinical pathways • Monitoring cost outliers (especially in uncomplicated groups) • Improving coding in medical records and registries

  18. Examples from Swedish data

  19. “Quality and Efficiency in Swedish Health Care” • 124 quality indicators in Health Care (Medical results, Patient experiences, Time related availability, Costs) Indicator A42: 28-days fatal rate for myocardial infarction, hospitalised patients • Trends over time • Benchmarking of Regions and hospitals Further analyses/questions: • Can the NordDRG-CC system change the ranking of hospitals when Benchmarking quality indicators? • Can the new CC-grouper explain mortality?

  20. Trends over time

  21. Regional comparisons

  22. Hospital comparisions 28-days fatal rate – Benchmarking of hospitals in Sweden standardized for age not for casemix

  23. Ranking of hospitals adjusted for age/casemix – top section 1. Color 2. Rank 3. Rank Casemix 4. Hospital

  24. Ranking – middle section

  25. Ranking – last sektion

  26. Percentage of deceased per age group and severity level 45,0% 40,0% 35,0% 30,0% 25,0% No CC Andel avlidna CC MCC 20,0% 15,0% 10,0% 5,0% 0,0% 0-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90ff Age group

  27. Discussion • Is the increased number of groups motivated in the new grouper? • Can the NordDRG-CC be of use for Quality and Efficiency studies? • How solid is the DRG-system for poor coding?

  28. Thank you for your attention! For more information: www.socialstyrelsen.se

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