1. DRG as a quality indicator 4th Nordic Casemix Conference 3-4th June 2010 Paasitorni, 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- 37 http://www.socialstyrelsen.se/publikationer2009/2009- 126-144 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. 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. 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. 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. 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