DRG as a quality indicatorDRG as a quality indicator

4th Nordic Casemix Conference

3-4th June 2010Paasitorni, Helsinki, Finland 

Lisbeth Serdén

National Board of Health and Welfare

GeneralGeneral

• 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

Transparency Transparency and benchmarkingand 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

Quality comparisonsQuality 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 processesEfficiency in health care – cardiac care

Improvement in codingImprovement 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

 

Increases productivityIncreases 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.

DRG in reimbursement systems DRG in reimbursement systems supports qualitysupports quality

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

International comparisonsInternational 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

Swedish quality outcomes on DRGSwedish 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

Cost per DRG point –specialised Cost per DRG point –specialised medical care 2008medical care 2008

Cost per DRG point –specialised Cost per DRG point –specialised medical caremedical 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

Diagnoses per case 2008Diagnoses per case 2008

Diagnoses per case in SwedenDiagnoses 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

The DRG system built-in logic on The DRG system built-in logic on incorrect coding, DRG 468, DRG 469, DRG incorrect coding, DRG 468, DRG 469, DRG 470 and DRG 477470 and DRG 477

The DRG system built-in logic on The DRG system built-in logic on incorrect codingincorrect 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’

Primary diagnosis Primary diagnosis

• Regional differences in choosing code for primary diagnosis

• Differences depending on– mortality?– coding habits?– influence from DRG?

• Some examples

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

DRG 140 Angina pectoris compared DRG 140 Angina pectoris compared to DRG 143 Chest painto 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

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

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

DRGs with complication out of DRGs DRGs with complication out of DRGs with and without complicationwith and without complication

DRGs with complicationDRGs 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

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

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

DRG 14A Stroke w cc compared to DRG 14A Stroke w cc compared to DRG 14B Stroke wo ccDRG 14B Stroke wo cc

DRG 14A Stroke w cc compared to DRG 14A Stroke w cc compared to DRG 14B Stroke wo ccDRG 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

Conclusion Conclusion Swedish quality outcomes on DRGSwedish 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

ConclusionsConclusions

• 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

Automatically control on qualityAutomatically 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

DRG 14A Stroke w cc and DRG 14B DRG 14A Stroke w cc and DRG 14B Stroke wo cc compared to DRG 15 Stroke wo cc compared to DRG 15 TIATIA

DRG 14A Stroke w cc and DRG 14B DRG 14A Stroke w cc and DRG 14B Stroke wo cc compared to DRG 15 Stroke wo cc compared to DRG 15 TIATIA• 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