DRG as a quality indicator

1. DRG as a quality indicator 4th Nordic Casemix Conference 3-4th June 2010Paasitorni, Helsinki, Finland Lisbeth Serdén National Board of Health and Welfare

2. General • There are other aspects of quality in health care then treatment policy and medical outcomes • DRG systems contribution to quality • by transparency in health care data • facilitate benchmarking • facilitate quality comparisons • increases the productivity • leads to improvement in coding • automatically control on data quality

3. Transparency and benchmarking • DRG contribute to transparency which leads to improvement in quality. Better description of hospital treatments increases the transparency of care and the possibility to compare and standardise the care provided • DRG benchmarking improves quality.   Example ‘Quality and Efficiency in Swedish Health Care. http://www.socialstyrelsen.se/publikationer2010/2010-4-37http://www.socialstyrelsen.se/publikationer2009/2009-126-144

4. Quality comparisons • Analyses on outliers in the DRG-system improve quality. Swedish analyses on outliers has contributed to a higher knowledge about why patients end up as outliers and how to avoid these situations • Analyses on health care processes Efficiency in health care – cardiac care

5. Improvement in coding • Introduction of DRG-systems leads to improvement in coding. Just the use of DRG-systems makes the users improve in coding • At least in Sweden the use of DRG has lead to widespread contribution on education in coding among the medical secretaries • More codes in the health care databases leads to a better description on health care • Education have impact on coding quality

6. Increases productivity • Introduction of DRG-systems increase the productivity which leads to improvement in access which is another aspect of quality • A good example is when Stockholm County Council implemented DRG in the beginning of 1990ths. There was a high increase in productivity the first two years that later turned to a weak decrease in productivity but the productivity stayed on a higher level.

7. DRG in reimbursement systems supports quality • DRG gives the possibility as a part of reimbursement systems to reward good quality with higher or extra payment

8. International comparisons • DRG is a mutual language which makes it possible to compare health care internationally • EuroDRG project • Thematic chapter on DRGs and quality • Analyses and comparisons on Appendectomy

9. Swedish quality outcomes on DRG • It is possible to measure data quality in health care in other ways then audits on case records • Studies on health care databases supply you with lots of information about the care provided and differences in health care consumption • Of course there is audits on case records performed in Sweden too

10. Cost per DRG point –specialised medical care 2008

11. Cost per DRG point –specialised medical care • Cost per DRG weighted case for the care that inhabitants of each region received – cost per consumed DRG point • This is an indicator of healthcare productivity i.e., performance in relation to costs • The County Council of Kalmar have the highest productivity, 10 percent over average

12. Diagnoses per case 2008

13. Diagnoses per case in Sweden • Successively increasing • 1997 there where 1.7 diagnoses per case • 2008 there where 2.6 diagnoses per case • From 2 to 3.3 diagnoses per case, regional level • The more information on diagnoses there are in the health care databases the more information you get

14. The DRG system built-in logic on incorrect coding, DRG 468, DRG 469, DRG 470 and DRG 477

15. The DRG system built-in logic on incorrect coding • In NordDRG • DRG 468 Rare or incorrect combination of diagnosis and extensive procedure • DRG 469 Unspecified or invalid discharge information (until 2008) • DRG 470 Ungroupable • DRG 477 Rare or incorrect combination of diagnosis and other procedure • Indicator on incorrect coding • Regional differences between 0.2 to 2.8 percent • The main reason is ‘primary diagnosis is missing’

16. Primary diagnosis • Regional differences in choosing code for primary diagnosis • Differences depending on • mortality? • coding habits? • influence from DRG? • Some examples

17. DRG 140 Angina pectoris compared to DRG 143 Chest pain, 2008

18. DRG 140 Angina pectoris compared to DRG 143 Chest pain • Definition on Angina pectoris and Chest pain in a State of the Art document from The National Board of Health and Welfare in 1998 • 42 percent Angina pectoris 2001 • 25 percent Angina pectoris 2008

19. DRG 88 Chronic obstructive pulmonary disease compared to DRG 96 and DRG 97 Bronchitis & asthma, age > 17 w cc/wo cc

20. DRG 88 Chronic obstructive pulmonary disease compared to DRG 96 and DRG 97 Bronchitis & asthma, age > 17 w cc/wo cc • In 2008 the relationship between DRG 88 and DRG 96 and 97 was 75 to 25 percent • Decreasing cases in inpatient care

21. DRGs with complication out of DRGs with and without complication

22. DRGs with complication • Regional difference is significant • Regional difference between 20 to 35 percent • Regions with a long tradition on DRGs have a higher share DRGs with complication. Except some regions, Västerbotten and Jönköping • Increasing share of complicated DRGs

23. DRG 210 Hip & femur procedures except major joint, age > 17, w cc compared to DRG 211 wo cc

24. DRG 210 Hip & femur procedures except major joint, age > 17, w cc compared to DRG 211 wo cc • There was an strong increase from 48 to 55 percent Hip & femur procedures w cc between 2007 and 2008 • Regional difference is significant • Highest share in Stockholm with 69 percent • Abuse in coding!? • Lowest share in County Council of Jämtland with12 percent

25. DRG 14A Stroke w cc compared to DRG 14B Stroke wo cc

26. DRG 14A Stroke w cc compared to DRG 14B Stroke wo cc • Increasing share of complicated DRGs in Stroke • There was an increase from 42 percent to 46 percent between 2007 and 2008 • Regions with high share of cases w cc have a strong connection to regions with a long tradition with DRG

27. Conclusion Swedish quality outcomes on DRG • A yearly report on quality outcomes are published • There is a great demand about more information on these issues • Improvement in data quality

28. Conclusions • DRG provides an opportunity to measure and improve quality that was not possible before • increases the awareness of quality • increases transparency about hospital activities • improvement in access • improvement in coding diagnoses • facilitates analyses on quality

29. Automatically control on quality • DRG systems automatically control on quality with respect to DRGs that indicate incorrect coding • In NordDRG • DRG 468 Rare or incorrect combination of diagnosis and extensive procedure • DRG 469 Unspecified or invalid discharge information (until 2008) • DRG 470 Ungroupable • DRG 477 Rare or incorrect combination of diagnosis and other procedure

30. DRG 14A Stroke w cc and DRG 14B Stroke wo cc compared to DRG 15 TIA

31. DRG 14A Stroke w cc and DRG 14B Stroke wo cc compared to DRG 15 TIA • Definition on Specific cerebrovascular disorders except TIA, Stroke, and Transient ischemic attac & precerebral occlusions, TIA, in a State of the Art document from The National Board of Health and Welfare in 1996 • 16 percent TIA 2001 • 19 percent TIA 2008