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Improvement of the NordDRG systems ability to describe performance - a new logic for comorbidity and/or complications Mona Heurgren Head of Unit Unit for.

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Presentation on theme: "Improvement of the NordDRG systems ability to describe performance - a new logic for comorbidity and/or complications Mona Heurgren Head of Unit Unit for."— Presentation transcript:

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 SjöliProject leader –Mona HeurgrenProject owner –Mats FernströmMedical advisor –Ralph DahlgrenMedical advisor –Gunnar HenrikssonMedical advisor –Liselotte SällSecretary –Åke KarlssonStatistician –Anders JacobssonStatistician –Martti VirtanenTechnical 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 MDC 4 Diseases and disorders of the Respiratory system S YESNO Diagnosis Category Chronic obstructive pulmonary disease CC/MCC NO YES Surgical DRGs Chronic obstructive pulmonary disease No CC Chronic obstructive pulmonary disease CC Chronic obstructive pulmonary disease MCC Cont. Logic – NordDRG-CC

12 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.

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


15 NordDRG-CC – example of weights Weight 1.0 – average in the cost database (trimmed)

16 More results NordDRG-CC The overall performance of the NordDRG system has improved: –R 2 (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

17 Uncomplicated Ceasarian Section

18 Number of cases in clusterds of variation in NordDRG-se compared to NordDRG-CC 0% 3% 8% 19% 20% 26% 15% 5% 2% 0% 4% 10% 20% 28% 23% 12% 2% 1% 0% 5% 10% 15% 20% 25% 30% <20% >20%<30%>30%<40%>40%<50%>50%<60%>60%<70%>70%<80%>80%<90% >90%<100% >100% CV (variationscoefficient) Andel vårdtillfällen NordDRG-se CC-grouper

19 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?

20 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

21 Examples from Swedish data


23 “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?

24 Trends over time

25 Regional comparisons

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

27 Ranking of hospitals adjusted for age/casemix – top section 11Visby lasarett 32Danderyds sjukhus 23Köpings lasarett 54Norrlands Universitetssjukhus 45Kullbergska sjukhuset 66Skellefteå lasarett 97Norrtälje sjukhus 178S:t Görans sjukhus 79Piteå Älvdals sjukhus 1510Värnamo sjukhus 2111Ängelholms sjukhus 1312Västerviks sjukhus 2613Södertälje sjukhus 1114Skaraborgs sjukhus 3615Kristianstads sjukhus 816Gävle sjukhus 2217Universitetssjukhuset i Linköping 1918Ryhov, länssjukhus 3219Södersjukhuset 1. Color 2. Rank 3. Rank Casemix 4. Hospital

28 Ranking – middle section 2920Västerås lasarett 3021Kungälvs sjukhus 4222Hässleholms sjukhus 1623Bollnäs sjukhus 1824Örnsköldsviks sjukhus 3725AKADEMISKA 1226Blekingesjukhuset 5627Halmstads sjukhus 1428Falu lasarett 2029Karolinska sjukhuset 2830Hudiksvalls sjukhus 4931Ystads lasarett 2732Lycksele lasarett 3833Sollefteå sjukhus 3334Mora lasarett 3935Kalix lasarett 4336Sundsvalls sjukhus 4637Torsby sjukhus 4038Universitetssjukhuset MAS

29 Ranking – last sektion 5239 Motala lasarett 4440 Varbergs sjukhus 3441 Östersunds sjukhus 3142 Universitetssjukhuset i Lund 2443 Länssjukhuset Kalmar 1044 Mälarsjukhuset 45 Sahlgrenska universitetssjukhuset 4846 Höglandssjukhuset 47 Vrinnevisjukhuset 5048 Helsingborgs lasarett 3549 Universitetssjukhuset Örebro 2350 Karlstads sjukhus 5551 NU-sjukvården 5352 SÄ-sjukvården 5153 Trelleborgs lasarett 2554 Nyköpings sjukhus 5955 Huddinge sjukhus 4156 Oskarshamns sjukhus 5457 Lindesbergs lasarett 6358 Ljungby lasarett 5859 Kiruna lasarett 6260 Växjö lasarett 6061 Arvika sjukhus 6162 Sunderbyns sjukhus 5763 Ludvika lasarett 64 Alingsås lasarett 65 Karlskoga lasarett 66 Gällivare lasarett

30 Percentage of deceased per age group and severity level 0,0% 5,0% 10,0% 15,0% 20,0% 25,0% 30,0% 35,0% 40,0% 45,0% 0-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-8990ff Age group Andel avlidna No CC CC MCC

31 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?

32 Thank you for your attention! For more information:

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