Improvement of the NordDRG Improvement of the NordDRG systems ability to describe systems ability to describe performance - a new logic for performance - a new logic for comorbidity and/or complicationscomorbidity and/or complications

Mona HeurgrenHead of Unit

Unit for Development of Quality and Efficiency Studies

The National Board of Health and Welfare Sweden

AgendaAgenda• 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

The scoop of casemix The scoop of casemix adjustmentsadjustments• 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

Why improve NordDRGs ability to Why improve NordDRGs ability to adjust for casemix?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

BackgroundBackground• 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).

AcknowledgementsAcknowledgements• 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

The aim of the projectThe 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

MethodMethod• 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

Criteria's for changing DRGsCriteria'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

The Scoop of NordDRG-CCThe 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)

NordDRG-CC, preliminary resultsNordDRG-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.

Stroke 014No:15 400Cost:52 377 SEKCV:78%

Stroke, NO CC, 014bNo:7 859Cost:42 871 SEKCV:75%

Stroke, CC, 014aNo: 7 541Kost:62 284 SEKCV:75%

NordDRG 2010 Stroke, NO CC,

014bNo: 7 235 Cost:40 737 SEKCV:70%

Stroke, CC, 014CCNo:6 635Cost:56 654 SEKCV:70%

Stroke, MCC, 014MCCNo: 1 530Cost:88 876 SEKCV:73%

NordDRG-CC

STROKE – Development of groping logic

Base DRG

2800002400002000001600001200008000040000

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Cost

Frequency

Stroke, Base DRG

Cost

Frequency

40737 28637 723556654 39551 663588876 65387 1530

Mean StDev N

A014BA014BCC

A014BMCC

Drg

Stoke with CC-Levels

NordDRG-CC – example of weightsNordDRG-CC – example of weights

• Weight 1.0 – average in the cost database (trimmed)

Drg Drgtxt WeightA011 Tumours in the nervous system, without CC/MCC 0,8570A011CC Tumours in the nervous system, with CC 1,2446A011MCC Tumours in the nervous system, with MCC 1,9631A012 Degenerative disorders in the nervous system, without CC/MCC 0,8848A012MCC Degenerative disorders in the nervous system, with CC/MCC 1,8501A014B Specific vascular disorders in the brain excl TIA, without CC/MCC 1,0565A014BCC Specific vascular disorders in the brain excl TIA, with CC 1,4036A014BMCC Specific vascular disorders in the brain excl TIA, with MCC 2,2348A015 TIA and occlusion of precerebral arteries, without CC/MCC 0,4858A015MCC TIA and occlusion of precerebral arteries, with CC/MCC 0,8667A019 Disorders in brain nerves and peripheral nerves, without CC/MCC 0,6012A019CC Disorders in brain nerves and peripheral nerves, with CC 0,8903A019MCC Disorders in brain nerves and peripheral nerves, with MCC 1,0419

More results NordDRG-CCMore 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

72000630005400045000360002700018000

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kost

Frequency

Mean 38939StDev 10045N 7606

Histogram of kostNormal

Uncomplicated Ceasarian Section

ConclusionsConclusions

• 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?

Areas of useAreas 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

Examples from Swedish dataExamples from Swedish data

““Quality and Efficiency in Quality and Efficiency in Swedish Health Care” 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?

Trends over timeTrends over time

Regional comparisonsRegional comparisons

Hospital comparisions28-days fatal rate –

Benchmarking of hospitals in Sweden

standardized for age not for casemix

Ranking of hospitals adjusted Ranking of hospitals adjusted for age/casemix – top sectionfor age/casemix – top section

  1 1 Visby lasarett                      3 2 Danderyds sjukhus                   2 3 Köpings lasarett                    5 4 Norrlands Universitetssjukhus       4 5 Kullbergska sjukhuset               6 6 Skellefteå lasarett                 9 7 Norrtälje sjukhus                   17 8 S:t Görans sjukhus                  7 9 Piteå Älvdals sjukhus               15 10 Värnamo sjukhus                     21 11 Ängelholms sjukhus                  13 12 Västerviks sjukhus                  26 13 Södertälje sjukhus                  11 14 Skaraborgs sjukhus                  36 15 Kristianstads sjukhus               8 16 Gävle sjukhus                       22 17 Universitetssjukhuset i Linköping   19 18 Ryhov, länssjukhus                  32 19 Södersjukhuset                    

1. Color 2. Rank 3. Rank Casemix 4. Hospital

Ranking – Ranking – middle sectionmiddle section  29 20 Västerås lasarett                   30 21 Kungälvs sjukhus                    42 22 Hässleholms sjukhus                 16 23 Bollnäs sjukhus                     18 24 Örnsköldsviks sjukhus               37 25 AKADEMISKA  12 26 Blekingesjukhuset                   56 27 Halmstads sjukhus                   14 28 Falu lasarett                       20 29 Karolinska sjukhuset                28 30 Hudiksvalls sjukhus                 49 31 Ystads lasarett                     27 32 Lycksele lasarett                   38 33 Sollefteå sjukhus                   33 34 Mora lasarett                       39 35 Kalix lasarett                      43 36 Sundsvalls sjukhus                  46 37 Torsby sjukhus   40 38 Universitetssjukhuset MAS         

Ranking – last sektionRanking – last sektion  52 39 Motala lasarett                     44 40 Varbergs sjukhus                    34 41 Östersunds sjukhus                  31 42 Universitetssjukhuset i Lund        24 43 Länssjukhuset Kalmar                10 44 Mälarsjukhuset                      45 45 Sahlgrenska universitetssjukhuset   48 46 Höglandssjukhuset                   47 47 Vrinnevisjukhuset                   50 48 Helsingborgs lasarett               35 49 Universitetssjukhuset Örebro        23 50 Karlstads sjukhus                   55 51 NU-sjukvården                       53 52 SÄ-sjukvården                       51 53 Trelleborgs lasarett                25 54 Nyköpings sjukhus                   59 55 Huddinge sjukhus                    41 56 Oskarshamns sjukhus                 54 57 Lindesbergs lasarett                63 58 Ljungby lasarett                    58 59 Kiruna lasarett                     62 60 Växjö lasarett                      60 61 Arvika sjukhus                      61 62 Sunderbyns sjukhus                  57 63 Ludvika lasarett                    64 64 Alingsås lasarett                   65 65 Karlskoga lasarett                  66 66 Gällivare lasarett                

Percentage of deceased per age group and severity level

0,0%

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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

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No CC

CC

MCC

DiscussionDiscussion

• 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?

Thank you for your attention!Thank you for your attention!

For more information:

www.socialstyrelsen.se