[The new treatment procedures of the DGUV from the perspective of an injury type procedure (VAV) clinic]. / Die neuen Heilverfahren der DGUV aus der Sicht einer VAV-Klinik.

The new treatment procedures of the German Statutory Accident Insurance (DGUV) have ramifications for the injury type procedure clinics (VAV) from medical, economic and structural aspects. Whereas the latter can be assessed as positive, the medical and economical aspects are perceived as being negative. Problems arise from the partially unclear formulation of the injury type catalogue, which results in unpleasant negotiations with the occupational insurance associations with respect to financial remuneration for services rendered. Furthermore, the medical competence of the VAV clinics will be reduced by the preset specifications of the VAV catalogue, which opens up an additional field of tension between medical treatment, fulfillment of the obligatory training and acquisition of personnel as well as the continually increasing economic pressure. From the perspective of the author, the relinquence of medical competence imposed by the regulations of the new VAV catalogue is "throwing the baby out with the bathwater" because many VAV clinics nationwide also partially have competence in the severe injury type procedure (SAV). A concrete "competence-based approval" for the individual areas of the VAV procedure would be sensible and would maintain the comprehensive care of insured persons and also increase or strengthen the willingness of participating VAV hospitals for unconditional implementation of the new VAV procedure.

Trialling diagnosis-related groups classification in the Iranian health system: a case study examining the feasibility of introducing casemix.

This paper examines the quality of routinely collected information in an Iranian hospital in a trial of casemix classification. Australian Refined Diagnosis Related Groups (AR-DRG) were used to classify patient episodes. There were 327 DRGs identified, of which 20% had only 1 case. The grouper program identified invalid records for 4% of total separations. Approximately 4.5% of cases were classified into error DRGs and 3.4% were ungroupable. No complication and comorbidity effects were identified with 93% of total cases. R2 (variance in length of stay explained) was 44% for untrimmed cases, increasing to 63%, 57% and 58% after trimming by L3H3, IQR and 10th-95th percentile methods respectively.

[F45.41: chronic pain disorder with somatic and psychological factors : a coding aid]. / F45.41 Chronische Schmerzstörung mit somatischen und psychischen Faktoren : Eine Kodierhilfe.

In 2009, the German version of ICD-10 (ICD-10 GM version 2009) introduced the diagnosis of "chronic pain disorder with somatic and psychological factors", because current ICD-10 diagnoses did not address the biopsychosocial character of chronic pain adequately. For most patients, a dichotomous classification into psychologically versus biomedically caused pain is inappropriate and does not reflect current knowledge on pain. The new code F45.41 addresses the relevance of psychological factors for chronic pain persistence and chronic pain treatment, even in those conditions with a clear biomedical cause at the beginning. This guideline describes how to use this new diagnosis, which boundaries have to be considered, and how comorbid and associated conditions can be classified. The distinction of this new diagnosis from other pain-associated diagnoses and recommendations for the coding of comorbid conditions are presented. The differentiation of everyday pain symptoms from pain disorders is outlined. Finally, contextual factors of the classification process, as well as problems in integrating this new diagnosis into diagnosis-related group (DRG) systems of financial reimbursement are discussed.

The effect of misclassification errors on case mix measurement.

Case mix systems have been implemented for hospital reimbursement and performance measurement across Europe and North America. Case mix categorizes patients into discrete groups based on clinical information obtained from patient charts in an attempt to identify clinical or cost difference amongst these groups. The diagnosis related group (DRG) case mix system is the most common methodology, with variants adopted in many countries. External validation studies of coding quality have confirmed that widespread variability exists between originally recorded diagnoses and re-abstracted clinical information. DRG assignment errors in hospitals that share patient level cost data for the purpose of establishing cost weights affects cost weight accuracy. The purpose of this study is to estimate bias in cost weights due to measurement error of reported clinical information. DRG assignment error rates are simulated based on recent clinical re-abstraction study results. Our simulation study estimates that 47% of cost weights representing the least severe cases are over weight by 10%, while 32% of cost weights representing the most severe cases are under weight by 10%. Applying the simulated weights to a cross-section of hospitals, we find that teaching hospitals tend to be under weight. Since inaccurate cost weights challenges the ability of case mix systems to accurately reflect patient mix and may lead to potential distortions in hospital funding, bias in hospital case mix measurement highlights the role clinical data quality plays in hospital funding in countries that use DRG-type case mix systems. Quality of clinical information should be carefully considered from hospitals that contribute financial data for establishing cost weights.

Use of risk-adjusted change in health status to assess the performance of integrated service networks in the Veterans Health Administration.

OBJECTIVE: Health outcome assessments have become an expectation of regulatory and accreditation agencies. We examined whether a clinically credible risk adjustment methodology for the outcome of change in health status can be developed for performance assessment of integrated service networks. STUDY DESIGN: Longitudinal study. SETTING: Outpatient. STUDY PARTICIPANTS: Thirty-one thousand eight hundred and twenty-three patients from 22 Veterans Health Administration (VHA) integrated service networks were followed for 18 months. MAIN MEASURE: The physical (PCS) and mental (MCS) component scales from the Veterans Rand 36-items Health Survey (VR-36) and mortality. The outcomes were decline in PCS (decline in PCS scores greater than -6.5 points or death) and MCS (decline in MCS scores greater than -7.9 points). RESULTS: Four thousand three hundred and twenty-eight (13.6%) patients showed a decline in PCS scores greater than -6.5 points, 4322 (13.5%) had a decline in MCS scores by more than -7.9 points, and 1737 died (5.5%). Multivariate logistic regression models were used to adjust for case-mix. The models performed reasonably well in cross-validated tests of discrimination (c-statistics = 0.72 and 0.68 for decline in PCS and MCS, respectively) and calibration. The resulting risk-adjusted rates of decline in PCS and MCS and ranks of the networks differed considerably from unadjusted ratings. CONCLUSION: It is feasible to develop clinically credible risk adjustment models for the outcomes of decline in PCS and MCS. Without adequate controls for case-mix, we could not determine whether poor patient outcomes reflect poor performance, sicker patients, or other factors. This methodology can help to measure and report the performance of health care systems.

Do different case-mix measures affect assessments of provider efficiency? Lessons from the Department of Veterans Affairs.

Although case-mix adjustment is critical for provider profiling, little is known regarding whether different case-mix measures affect assessments of provider efficiency. We examine whether two case-mix measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), result in different assessments of efficiency across service networks within the Department of Veterans Affairs (VA). Three profiling indicators examine variation in resource use. Although results from the ACGs and DCGs generally agree on which networks have greater or lesser efficiency than average, assessments of individual network efficiency vary depending upon the case-mix measure used. This suggests that caution should be used so that providers are not misclassified based on reported efficiency.

Provider groups, health plans use software to get accurate estimates of capitated expenses.

Information technology is improving the ability of health care organizations to predict annual expenses for groups of patients and to fairly allocate payments to providers based on health risk adjustments. Here's one capitated group's successful formula.

Seniors' need for and use of Medicare home health services.

This study examined: (a) nature and extent of seniors' need for care both at time of admission to and discharge from Medicare home health services, and (b) relationships among admission need, service utilization, need at discharge, and discharge disposition for one episode of home care services. The sample of 195 was stratified by home health discharge disposition: (a) acute group, (b) chronic group, and (c) stable home group. Two classification systems were used to access the seniors' level of need, the mandated Medicare case-mix system (CMS) and a holistic intensity of need system. Findings show that there were no differences in services received by the three groups, that discharge did not mean seniors' need for home care services had been eliminated or reduced, and that caregiver support impacts seniors' need for home care.

Empirical comparison of DRG variants using cardiovascular surgery data: initial results of a project at 18 German hospitals.

In 2000, the responsibility for selecting a DRG variant for use in Germany was assigned to a body comprising representatives of hospitals and insurers called the Self-Administration Board (or Board in this paper). To help the Board, we applied cardiac surgery data from 18 German hospitals to eight different DRG variants. The error caused by bad coding quality could be minimized this way, since all diagnoses and procedures in cardiac surgery must be recorded for quality assurance purposes. To match the German code to the appropriate code required by the DRG variant, we created mapping tables whenever needed. As far as cardiac surgery is concerned, the Australian AR-DRG and the French GHM variants provided the best medical relevance, while the AR-DRG variant considered the level of severity better. Other variants would have to be updated to better reflect the level of medical complexity. Three main causes for wrong grouping could be identified for all systems: incomplete mapping, not enough reference to multidisciplinary treatments, and system construction problems.

Patient reported quality of care before vs. after the implementation of a diagnosis related groups (DRG) classification and payment system in one Swedish county.

Patient reported quality of care before vs. after the implementation of a diagnosis related groups (DRG) classification and payment system in one Swedish county. The purpose was to evaluate the effects of a diagnosis related groups (DRG)-intervention on the quality of care as perceived by patients at two surgical clinics in the County Council of Gävleborg, Sweden. The study was planned as a nonequivalent control groups design, but external factors turned it into a prospective longitudinal design. Changes in patient experiences of received care were evaluated for the period 1992-1996. Of the 40 included consecutive patients per year from each hospital, > 85% completed the questionnaire. The selection of patients was defined by diagnoses and surgical treatments, and by geographical area. The results demonstrated a decrease of the quality of care as seen from the patient perspective, especially with respect to treatment by staff. Previously stated DRG goals were partially fulfilled and the DRG-intervention was gradually implemented. Other presumed causal variables were: other reforms, restrained resources, quality assurance activities, organizational and structural changes within the county council. Further studies of the effects of health care reforms would yield more distinct conclusions, provided it would be possible to evaluate interventions prior to full-scale implementation.

Casemix classification systems.

The idea of using casemix classification to manage hospital services is not new, but has been limited by available technology. It was not until after the introduction of Medicare in the United States in 1965 that serious attempts were made to measure hospital production in order to contain spiralling costs. This resulted in a system of casemix classification known as diagnosis related groups (DRGs). This paper traces the development of DRGs and their evolution from the initial version to the All Patient Refined DRGs developed in 1991.

Casemix and nursing.

The American Nurses' Association did not embrace the introduction of diagnosis related groups, believing they would not recognise nursing activity nor acuity and would bring about the economic demise of nursing. Australian nurses, by contrast, recognised the window of opportunity that the work towards Australian national diagnosis related groups and funding mechanisms provided to move nursing resources into the political and policy mainstream. This paper reviews the American and Australian nursing experience with casemix, acuity and cost weighting. It uses examples from more recent work to argue for the use of casemix information in new ways, for 'process improvement' or 'evidence-based management'. The paper concludes that the next great leap forward in casemix may require attention to building the information and human infrastructures, so that the valuable clinical-financial information produced by casemix-based information systems can truly inform management and policy.

High-resource hospital users in an integrated delivery system.

OBJECTIVES: With decreasing healthcare reimbursement, nurse administrators need to aggressively manage care for high-resource users of hospital services to ensure the viability of their healthcare organization. The objective of this study was to (1) investigate frequent Medicare inpatient admission and emergency department users, (2) investigate Medicare day outliers, and (3) examine Medicare reimbursement/charge ratios. BACKGROUND: Although much research has focused on patients who have been readmitted frequently to the hospital, little research has examined patients who are frequent users of both emergency departments and inpatient services. METHODS: In this study, all 4,920 elderly Medicare inpatient admissions and emergency department visits for 1 year in a 222-bed general hospital were included. Patient profiles of two categories of high resource users were created. RESULTS: Results showed the frequent high user group (n = 75), who had six or more combined emergency department and inpatient admissions per year, had cardiac, diabetic, and chronic respiratory conditions, and came to the hospital from their homes. The day outlier profile (n = 148) consisted of older patients who have neoplasms, and respiratory and circulatory diseases. The mean Medicare reimbursement/charge ratio varied for high volume diagnosis-related groups (DRGS.) IMPLICATIONS: From the study, implications include refining case management, monitoring high-resource patients by computer tracking, analyzing high-user trends by several different methods, incorporating many facets of an integrated healthcare delivery into their care, expanding patient, outpatient, and community support programs, and continually monitoring revenue for organizational viability.

Risk-sharing integration efforts in the hospital sector.

The extent of hospital involvement in integrated delivery systems (IDSs) during 1996 was assessed by a national sample of 235 short-term private general hospitals. Two out of five hospitals were participating in networks with some financial risk sharing, and another third reported membership in IDS networks without financial obligations. Managed care's presence was the only significant factor moving hospitals from a stand-alone status to network membership. The decision to share financial risk was influenced not only by managed care pressures, but also by the level of local hospital competition and the severity of the inpatient case mix.

Summary of ICD-9-CM Coordination and Maintenance Committee meeting.

The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Health Care Financing Administration (HCFA), recently met in Baltimore, MD. Donna Pickett, RRA (NCHS), and Patricia Brooks, RRA (HCFA), cochaired the meeting. Proposed modifications to ICD-9-CM were presented and are summarized below. Unless otherwise indicated, the audience generally supported the proposed changes.

A classification scheme for outcome indicators.

PURPOSE: To provide a framework for classifying outcome indicators for a more comprehensive view of outcomes and quality. METHODS: Review of outcomes literature published since 1974 from medicine, nursing, and health services research to identify indicators. Outcome indicators were clustered inductively. FINDINGS: Three groups of outcome indicators were identified: patient-focused, provider-focused, and organization-focused. Although investigators tend to focus on a select few outcome indicators, such as patient satisfaction, quality of life, and mortality, many indicators exist to measure outcomes. CONCLUSIONS: Selecting and integrating a wide array of outcome indicators from the various categories will provide a more balanced view of health care delivery as compared with focusing on a few common indicators or only one category.

Measuring the unmeasurable: a caring science perspective on patient classification.

AIMS: To give a short historical survey of patient classification and its motives, to analyse patient classification and especially the instrument, The Oulu Patient Classification more closely from a caring science perspective. BACKGROUND: A survey of topical literature and research on patient classification show that economic and administrative justifications predominate and the caring science connection is weak, almost non-existent. ORIGINS OF INFORMATION: Topical literature and research on patient classification and the instrument, The Oulu Patient Classification. DATA ANALYSIS: Topical literature and research were evaluated from a caring science perspective in accordance with Eriksson's theory of caring and the basic concept of man as an entity of body, soul and spirit. KEY ISSUES: Patient classification is used in staff planning and is also justified from the viewpoint of content, that is, as a method of guaranteeing good quality in the care of patients and as an expression of the prevalent caring ideology. The concept of man is reduced in current literature and research on patient classification. The Oulu Patient Classification is based on a humanistic view of man, but man's spiritual and existential needs do not emerge clearly from the manual of the instrument. CONCLUSIONS: It is essential for patient classification to start from a caring perspective. Correctly dimensioned staffing based on patient classification is a prerequisite for good care. This should be combined with a caring culture that considers the whole complexity of man in order to make good care possible.