Incremental cost of nosocomial bacteremia according to the focus of infection and antibiotic sensitivity of the causative microorganism in a university hospital.

To estimate the incremental cost of nosocomial bacteremia according to the causative focus and classified by the antibiotic sensitivity of the microorganism.Patients admitted to Hospital del Mar in Barcelona from 2005 to 2012 were included. We analyzed the total hospital costs of patients with nosocomial bacteremia caused by microorganisms with a high prevalence and, often, with multidrug-resistance. A control group was defined by selecting patients without bacteremia in the same diagnosis-related group.Our hospital has a cost accounting system (full-costing) that uses activity-based criteria to estimate per-patient costs. A logistic regression was fitted to estimate the probability of developing bacteremia (propensity score) and was used for propensity-score matching adjustment. This propensity score was included in an econometric model to adjust the incremental cost of patients with bacteremia with differentiation of the causative focus and antibiotic sensitivity.The mean incremental cost was estimated at &OV0556;15,526. The lowest incremental cost corresponded to bacteremia caused by multidrug-sensitive urinary infection (&OV0556;6786) and the highest to primary or unknown sources of bacteremia caused by multidrug-resistant microorganisms (&OV0556;29,186).This is one of the first analyses to include all episodes of bacteremia produced during hospital stays in a single study. The study included accurate information about the focus and antibiotic sensitivity of the causative organism and actual hospital costs. It provides information that could be useful to improve, establish, and prioritize prevention strategies for nosocomial infections.

Impacto económico de las bacteriemias nosocomiales. Comparación de tres metodologías de cálculo / Economic impact of nosocomial bacteraemia. A comparison of three calculation methods

INTRODUCCIÓN: El coste incremental que comportan las bacteriemias nosocomiales (BN) se utiliza como medida del impacto de estas infecciones. Los métodos tradicionales de cálculo de coste sobrestiman este incremento al no contemplar variables confusoras. El objetivo de este trabajo es comparar 3 metodologías de cálculo del coste incremental de la BN para corregir los sesgos presentes en análisis previos. MÉTODOS: Se compararon los pacientes que presentaron algún episodio de BN entre 2005 y 2007, con los pacientes con la misma patología sin BN. Los microorganismos causantes se agruparon según la tinción Gram y según si la bacteriemia era monomicrobiana o polimicrobiana, o producida por un hongo. Se compararon 3 métodos de cálculo: 1) estratificación por patología; 2) ajuste econométrico multivariante mediante un modelo lineal generalizado (MLG), y 3) un propensity score matching (PSM) antes del análisis multivariante para controlar los sesgos. RESULTADOS: Se analizaron 640 hospitalizaciones con BN y 28.459 sin BN; el coste medio observado fue de 24.515 € y 4.851,6 €, respectivamente. En la estratificación por patología, el coste incremental medio estimado fue de 14.735 €, el grupo de microorganismos que ocasionó menor coste incremental fue el de grampositivos, con 10.051€. En el MLG el coste incremental medio estimado fue de 20.922 €, mientras que utilizando PSM se estimó un coste incremental medio de 11.916 €. En las 3 estimaciones hay diferencias importantes según el grupo de microorganismos. CONCLUSIONES: Utilizar metodologías más elaboradas mejora el ajuste en este tipo de estudios e incrementa el valor de los resultados obtenidos

INTRODUCTION: The excess cost associated with nosocomial bacteraemia (NB) is used as a measurement of the impact of these infections. However, some authors have suggested that traditional methods overestimate the incremental cost due to the presence of various types of bias. The aim of this study was to compare three assessment methods of NB incremental cost to correct biases in previous analyses. METHODS: Patients who experienced an episode of NB between 2005 and 2007 were compared with patients grouped within the same All Patient Refined-Diagnosis-Related Group (APR-DRG) without NB. The causative organisms were grouped according to the Gram stain, and whether bacteraemia was caused by a single or multiple microorganisms, or by a fungus. Three assessment methods are compared: stratification by disease; econometric multivariate adjustment using a generalised linear model (GLM); and propensity score matching (PSM) was performed to control for biases in the econometric model. RESULTS: The analysis included 640 admissions with NB and 28,459 without NB. The observed mean cost was €24,515 for admissions with NB and €4,851.6 for controls (without NB). Mean incremental cost was estimated at €14,735 in stratified analysis. Gram positive microorganism had the lowest mean incremental cost, €10,051. In the GLM, mean incremental cost was estimated as €20,922, and adjusting with PSM, the mean incremental cost was €11,916. The three estimates showed important differences between groups of microorganisms. CONCLUSIONS: Using enhanced methodologies improves the adjustment in this type of study and increases the value of the results

Cost Attributable to Nosocomial Bacteremia. Analysis According to Microorganism and Antimicrobial Sensitivity in a University Hospital in Barcelona.

AIM: To calculate the incremental cost of nosocomial bacteremia caused by the most common organisms, classified by their antimicrobial susceptibility. METHODS: We selected patients who developed nosocomial bacteremia caused by Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, or Pseudomonas aeruginosa. These microorganisms were analyzed because of their high prevalence and they frequently present multidrug resistance. A control group consisted of patients classified within the same all-patient refined-diagnosis related group without bacteremia. Our hospital has an established cost accounting system (full-costing) that uses activity-based criteria to analyze cost distribution. A logistic regression model was fitted to estimate the probability of developing bacteremia for each admission (propensity score) and was used for propensity score matching adjustment. Subsequently, the propensity score was included in an econometric model to adjust the incremental cost of patients who developed bacteremia, as well as differences in this cost, depending on whether the microorganism was multidrug-resistant or multidrug-sensitive. RESULTS: A total of 571 admissions with bacteremia matched the inclusion criteria and 82,022 were included in the control group. The mean cost was € 25,891 for admissions with bacteremia and € 6,750 for those without bacteremia. The mean incremental cost was estimated at € 15,151 (CI, € 11,570 to € 18,733). Multidrug-resistant P. aeruginosa bacteremia had the highest mean incremental cost, € 44,709 (CI, € 34,559 to € 54,859). Antimicrobial-susceptible E. coli nosocomial bacteremia had the lowest mean incremental cost, € 10,481 (CI, € 8,752 to € 12,210). Despite their lower cost, episodes of antimicrobial-susceptible E. coli nosocomial bacteremia had a major impact due to their high frequency. CONCLUSIONS: Adjustment of hospital cost according to the organism causing bacteremia and antibiotic sensitivity could improve prevention strategies and allow their prioritization according to their overall impact and costs. Infection reduction is a strategy to reduce resistance.

Long-term costs of colorectal cancer treatment in Spain.

BACKGROUND: Assessing the long-term cost of colorectal cancer (CRC) increases our understanding of the disease burden. The aim of this paper is to estimate the long-term costs of CRC care by stage at diagnosis and phase of care in the Spanish National Health Service. METHODS: Retrospective study on resource use and direct medical cost of a cohort of 699 patients diagnosed and treated for CRC in 2000-2006, with follow-up until 30 June 2011, at Hospital del Mar (Barcelona). The Kaplan-Meier sample average estimator was used to calculate observed 11-year costs, which were then extrapolated to 16 years. Bootstrap percentile confidence intervals were calculated for the mean long-term cost per patient by stage. Phase-specific, long-term costs for the entire CRC cohort were also estimated. RESULTS: With regard to stage at diagnosis, the mean long-term cost per patient ranged from €20,708 (in situ) to €47,681 (stage III). The estimated costs increased at more advanced stages up to stage III and then substantially decreased in stage IV. In terms of treatment phase, the mean cost of the initial period represented 24.8 % of the total mean long-term cost, whereas the cost of continuing and advanced care phases represented 16.9 and 58.3 %, respectively. CONCLUSIONS: This study is the first to provide long-term cost estimates for CRC treatment, by stage at diagnosis and phase of care, based on data from clinical practice in Spain, and it will contribute useful information for future studies on cost-effectiveness and budget impact of different therapeutic innovations in Spain.

[Economic impact of nosocomial bacteraemia. A comparison of three calculation methods]. / Impacto económico de las bacteriemias nosocomiales. Comparación de tres metodologías de cálculo.

INTRODUCTION: The excess cost associated with nosocomial bacteraemia (NB) is used as a measurement of the impact of these infections. However, some authors have suggested that traditional methods overestimate the incremental cost due to the presence of various types of bias. The aim of this study was to compare three assessment methods of NB incremental cost to correct biases in previous analyses. METHODS: Patients who experienced an episode of NB between 2005 and 2007 were compared with patients grouped within the same All Patient Refined-Diagnosis-Related Group (APR-DRG) without NB. The causative organisms were grouped according to the Gram stain, and whether bacteraemia was caused by a single or multiple microorganisms, or by a fungus. Three assessment methods are compared: stratification by disease; econometric multivariate adjustment using a generalised linear model (GLM); and propensity score matching (PSM) was performed to control for biases in the econometric model. RESULTS: The analysis included 640 admissions with NB and 28,459 without NB. The observed mean cost was €24,515 for admissions with NB and €4,851.6 for controls (without NB). Mean incremental cost was estimated at €14,735 in stratified analysis. Gram positive microorganism had the lowest mean incremental cost, €10,051. In the GLM, mean incremental cost was estimated as €20,922, and adjusting with PSM, the mean incremental cost was €11,916. The three estimates showed important differences between groups of microorganisms. CONCLUSIONS: Using enhanced methodologies improves the adjustment in this type of study and increases the value of the results.

Hospital Costs Associated With Agitation in the Acute Care Setting.

OBJECTIVE: The study determined hospital costs associated with a diagnosis of agitation among patients at 14 general hospitals in Spain. METHODS: Data from discharge records of adult patients (2008-2012) with a diagnosis of agitation (ICD-9-CM code 293.0) were analyzed. Incremental hospital costs for agitated patients and a control group of patients without agitation were quantified, and the adjusted cost and incremental cost for both groups were compared by use of a recycled-predictions approach. RESULTS: The analysis included 355,496 hospital discharges, 5,334 of which were of patients with a diagnosis of agitation. Among patients with a diagnosis of agitation, hospital stays were significantly longer (12 days versus nine days). A significant difference in mean costs of €472 (95% confidence interval [CI]=€351-€593) was noted between patients with agitation and those in the control group. A recycled-predictions approach showed a difference of €1,593(CI=€1,556-€1,631). CONCLUSIONS: Findings indicate that agitation increased the use of hospital resources by at least 8%.

Estimación del coste hospitalario del cáncer colorrectal en Cataluña / Estimation of hospital costs of colorectal cancer in Catalonia (Spain)

Objetivo: Estimar el coste hospitalario del tratamiento del cáncer colorrectal (CCR) según estadio, tipo de coste y fase de evolución de la enfermedad en un hospital público. Métodos: Se realizó un estudio retrospectivo de costes de la atención hospitalaria del CCR de una cohorte de 699 pacientes con diagnóstico y tratamiento de CCR entre los años 2000 y 2006 en el Hospital del Mar, con seguimiento de hasta 5 años desde el diagnóstico de la enfermedad, a partir de bases de datos clínico-administrativas. Se analizó el coste medio por estadio, tipo de coste y fase de evolución de la enfermedad. Resultados: El coste medio por paciente en casos con diagnóstico in situ fue de 6573 Euros. Este coste aumentó en estadios más avanzados y llegó a los 36.894 Euros en el estadio III. Los principales componentes del coste fueron la cirugía-hospitalización (59,2%) y la quimioterapia (19,4%). En estadios más avanzados, el peso de la cirugía-hospitalización disminuyó, mientras que el de la quimioterapia aumentó. Conclusión: Este estudio proporciona el coste hospitalario del tratamiento del CCR calculado a partir de la práctica clínica habitual. La cirugía y el tratamiento quimioterápico son los principales componentes del coste. Los resultados obtenidos aportarán la información necesaria para los análisis de coste-efectividad de distintas iniciativas preventivas e innovaciones terapéuticas en nuestro entorno (AU)

Objective: To assess the hospital cost associated with colorectal cancer (CRC) treatment by stage at diagnosis, type of cost and disease phase in a public hospital. Methods: A retrospective analysis was conducted of the hospital costs associated with a cohort of 699 patients diagnosed with CRC and treated for this disease between 2000 and 2006 in a teaching hospital and who had a 5-year follow-up from the time of diagnosis. Data were collected from clinical-administrative databases. Mean costs per patient were analysed by stage at diagnosis, cost type and disease phase. Results: The mean cost per patient ranged from 6,573 Euros for patients with a diagnosis of CRC in situto 36,894 Euros in those diagnosed in stage III. The main cost components were surgery-inpatient care (59.2%) and chemotherapy (19.4%). Advanced disease stages were associated with a decrease in the relative weight of surgical and inpatient care costs and an increase in chemotherapy costs. Conclusions: This study provides the costs of CRC treatment based on clinical practice, with chemotherapy and surgery accounting for the major cost components. This cost analysis is a baseline study that will provide a useful source of information for future studies on cost-effectiveness and on the budget impact of different therapeutic innovations in Spain (AU)

[Estimation of hospital costs of colorectal cancer in Catalonia (Spain)]. / Estimación del coste hospitalario del cáncer colorrectal en Cataluña.

OBJECTIVE: To assess the hospital cost associated with colorectal cancer (CRC) treatment by stage at diagnosis, type of cost and disease phase in a public hospital. METHODS: A retrospective analysis was conducted of the hospital costs associated with a cohort of 699 patients diagnosed with CRC and treated for this disease between 2000 and 2006 in a teaching hospital and who had a 5-year follow-up from the time of diagnosis. Data were collected from clinical-administrative databases. Mean costs per patient were analysed by stage at diagnosis, cost type and disease phase. RESULTS: The mean cost per patient ranged from 6,573 Euros for patients with a diagnosis of CRC in situ to 36,894 € in those diagnosed in stage III. The main cost components were surgery-inpatient care (59.2%) and chemotherapy (19.4%). Advanced disease stages were associated with a decrease in the relative weight of surgical and inpatient care costs and an increase in chemotherapy costs. CONCLUSIONS: This study provides the costs of CRC treatment based on clinical practice, with chemotherapy and surgery accounting for the major cost components. This cost analysis is a baseline study that will provide a useful source of information for future studies on cost-effectiveness and on the budget impact of different therapeutic innovations in Spain.

Impacto económico de los eventos adversos en los hospitales españoles a partir del Conjunto Mínimo Básico de Datos / Assessing the economic impact of adverse events in Spanish hospitals by using administrative data

Objetivo Evaluar la incidencia y los costes de los eventos adversos presentes en el Conjunto Mínimo Básico de Datos (CMBD) en los hospitales españoles en el período 2008-2010.MétodoEstudio retrospectivo que estima el coste incremental por episodio, según la presencia de eventos adversos. El coste se obtiene de la Red Española de Costes Hospitalarios (RECH), creada a partir de los registros de costes por paciente basados en actividades y CMBD. Los eventos adversos se han identificado mediante Indicadores de Seguridad del Paciente (validados en el Sistema Sanitario español) de la Agency of Healthcare Research and Quality, junto a indicadores del proyecto europeo EuroDRG. Resultados Se incluyen 245.320 episodios, con un coste de 1.308.791.871 Euros. Aproximadamente 17.000 episodios (6,8%) sufrieron un evento adverso, lo que representa un 16,2% del coste total. Los eventos adversos, ajustados por el Grupo Relacionado por el Diagnóstico, añaden un coste incremental medio que oscila entre 5.260 Euros y 11.905 Euros. Seis de los diez eventos adversos con mayor coste incremental son posteriores a intervenciones quirúrgicas. El coste incremental total de los eventos adversos es de 88.268.906Euros, un 6,7% adicional del total del gasto sanitario. Conclusiones Valorando su impacto, los eventos adversos representan relevantes costes que pueden revertirse en mejora de la calidad y la seguridad del sistema de salud (AU)

Objective To evaluate the incidence and costs of adverse events registered in an administrative dataset in Spanish hospitals from 2008 to 2010.MethodsA retrospective study was carried out that estimated the incremental cost per episode, depending on the presence of adverse events. Costs were obtained from the database of the Spanish Network of Hospital Costs. This database contains data from 12 hospitals that have costs per patient records based on activities and clinical records. Adverse events were identified through the Patient Safety Indicators (validated in the Spanish Health System) created by the Agency for Healthcare Research and Quality together with indicators of the EuroDRG European project. Results This study included 245,320 episodes with a total cost of 1,308,791,871 Euros. Approximately 17,000 patients (6.8%) experienced an adverse event, representing 16.2% of the total cost. Adverse events, adjusted by diagnosis-related groups, added a mean incremental cost of between Euros 5,260 and Euros11,905. Six of the 10 adverse events with the highest incremental cost were related to surgical interventions. The total incremental cost of adverse events was Euros 88,268,906, amounting to an additional 6.7% of total health expenditure. Conclusions Assessment of the impact of adverse events revealed that these episodes represent significant costs that could be reduced by improving the quality and safety of the Spanish Health System (AU)

[Assessing the economic impact of adverse events in Spanish hospitals by using administrative data]. / Impacto económico de los eventos adversos en los hospitales españoles a partir del Conjunto Mínimo Básico de Datos.

OBJECTIVE: To evaluate the incidence and costs of adverse events registered in an administrative dataset in Spanish hospitals from 2008 to 2010. METHODS: A retrospective study was carried out that estimated the incremental cost per episode, depending on the presence of adverse events. Costs were obtained from the database of the Spanish Network of Hospital Costs. This database contains data from 12 hospitals that have costs per patient records based on activities and clinical records. Adverse events were identified through the Patient Safety Indicators (validated in the Spanish Health System) created by the Agency for Healthcare Research and Quality together with indicators of the EuroDRG European project. RESULTS: This study included 245,320 episodes with a total cost of 1,308,791,871€. Approximately 17,000 patients (6.8%) experienced an adverse event, representing 16.2% of the total cost. Adverse events, adjusted by diagnosis-related groups, added a mean incremental cost of between €5,260 and €11,905. Six of the 10 adverse events with the highest incremental cost were related to surgical interventions. The total incremental cost of adverse events was € 88,268,906, amounting to an additional 6.7% of total health expenditure. CONCLUSIONS: Assessment of the impact of adverse events revealed that these episodes represent significant costs that could be reduced by improving the quality and safety of the Spanish Health System.

Hospital de día: análisis de resultados, costes y asignación de recursos en neumología / The Day Hospital: Analysis of Results, Costs and Management of Pneumology Resources

Antecedentes: Los hospitales de día de neumología constituyen un instrumento relativamente nuevo de atención al paciente respiratorio complejo. Faltan estudios sobre su eficacia y eficiencia. Objetivo: Estudiar el impacto de la instauración de un hospital de día neumológico en una institución terciaria de 500 camas. Metodología: Análisis de eficacia, eficiencia y calidad. Resultados: En el período analizado (2 años) el hospital de día incrementó progresivamente su actividad. Esto se acompañó de mayor actividad clínica global en neumología, pero también de una reducción en el número de altas hospitalarias, aunque en el período estudiado no varió la presión de pacientes sobre urgencias. Como consecuencia, también se redujo la necesidad de camas en la sala de hospitalización convencional. Por otra parte, aumentó la complejidad de los pacientes ingresados, aunque la eficiencia (razón de funcionamiento estándar) y calidad (reingresos y mortalidad) de la atención en ese dispositivo se mantuvieron estables. Conclusiones: Los hospitales de día neumológicos constituyen un instrumento útil en la gestión de la atención a pacientes respiratorios, ya que reducen las necesidades de hospitalización, manteniendo la calidad asistencial y complementando otros dispositivos(AU)

Background: Day hospital units specialized in pulmonology are a relatively new instrument for providing care to complex respiratory patients. However, the number of studies focused on the efficacy and efficiency of day hospitals is scarce. Aim: Therefore, the aim of the present study was to analyze the effects of implementing a specialized respiratory day hospital in a standard teaching hospital with 500 beds. Methods: An analysis of efficacy, efficiency and quality care. Results: Throughout the study period (2 years) the day hospital progressively increased its activity. Although patient pressure on the emergency department remained constant, this was associated with a parallel increase in the overall medical activity of the Pulmonology Department and a reduction in the number of discharges from the hospital. There was a reduction in the number of admissions, and consequently in the need for beds in the Pulmonology Department. The complexity of the hospitalized patients increased, although the efficiency (standard functioning ratio) and quality (readmissions and mortality) of patient care remained stable. Conclusion: Day hospital pulmonology units are a useful tool in the management of respiratory patient care. They reduce the need for hospitalizations, while maintaining healthcare quality and complementing other care management instruments(AU)

Knee replacement and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

PURPOSE: Researchers from 11 countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their Diagnosis-Related Group (DRG) systems deal with knee replacement cases. The study aims to assist knee surgeons and national authorities to optimize the grouping algorithm of their DRG systems. METHODS: National or regional databases were used to identify hospital cases treated with a procedure of knee replacement. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97 % of cases. Five standardized case scenarios were defined and quasi-prices according to national DRG-based hospital payment systems ascertained. RESULTS: Grouping algorithms for knee replacement vary widely across countries: they classify cases according to different variables (between one and five classification variables) into diverging numbers of DRGs (between one and five DRGs). Even the most expensive DRGs generally have a cost index below 2.00, implying that grouping algorithms do not adequately account for cases that are more than twice as costly as the index DRG. Quasi-prices for the most complex case vary between euro 4,920 in Estonia and euro 14,081 in Spain. CONCLUSIONS: Most European DRG systems were observed to insufficiently consider the most important determinants of resource consumption. Several countries' DRG system might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities. Ultimately, this would contribute to assuring adequate performance comparisons and fair hospital reimbursement on the basis of DRGs.

The day hospital: analysis of results, costs and management of pneumology resources.

BACKGROUND: Day hospital units specialized in pulmonology are a relatively new instrument for providing care to complex respiratory patients. However, the number of studies focused on the efficacy and efficiency of day hospitals is scarce. AIM: Therefore, the aim of the present study was to analyze the effects of implementing a specialized respiratory day hospital in a standard teaching hospital with 500 beds. METHODS: An analysis of efficacy, efficiency and quality care. RESULTS: Throughout the study period (2 years) the day hospital progressively increased its activity. Although patient pressure on the emergency department remained constant, this was associated with a parallel increase in the overall medical activity of the Pulmonology Department and a reduction in the number of discharges from the hospital. There was a reduction in the number of admissions, and consequently in the need for beds in the Pulmonology Department. The complexity of the hospitalized patients increased, although the efficiency (standard functioning ratio) and quality (readmissions and mortality) of patient care remained stable. CONCLUSION: Day hospital pulmonology units are a useful tool in the management of respiratory patient care. They reduce the need for hospitalizations, while maintaining healthcare quality and complementing other care management instruments.

Patient classification and hospital costs of care for acute myocardial infarction in nine European countries.

This study contributes to the literature on the performance of diagnosis-related groups (DRGs) for acute myocardial infarction (AMI) patients by evaluating in nine countries the factors--in addition to DRGs--that affect costs or length of stay and comparing the variation that can be explained with or without DRGs. We evaluate whether the existing DRGs for AMI patients would benefit from additional patient-related and treatment-related factors that are found in administrative data across countries. In most countries, the set of patient and quality variables performed better than the DRG variables. Our results suggest that DRG systems in all countries could be improved by including additional explanatory factors or by refining the existing DRGs. Our results suggest that for AMI and possibly for other related episodes, a refinement of DRGs to include information on patient severity, procedures and levels of complications could improve the ability of DRGs to explain resource use. It seems possible to improve DRG-like hospital payment systems through the inclusion of episode-specific variables.

Patient classification systems and hospital costs of care for knee replacement in 10 European countries.

Knee replacement is a common surgical procedure performed to relieve pain and disability from degenerative osteoarthritis. This study evaluates the ability of ten European diagnosis-related group (DRG) systems to explain variations in costs or in length of stay for knee replacements. We assessed three different models in predicting variation of cost and length of stay. The first model, M(D), included only DRG groups as explanatory variables; the second, M(P), used a set of patient-level variables; and the third, M(F), included all variables from both M(D) and M(P). The total number of DRGs used to group knee replacement is low, ranging from two to six. All DRG systems except one differentiate between primary knee replacement and revision surgery. Considerable differences exist in the rate of revision surgery. There is also high variation in mean cost (from € 3809 to € 8158) and in mean length of stay (LoS) (from 4.2 to 13.6 days). The explanatory power of DRGs varies from 21.5 to 72.5% with values of around 40% in most countries of the study. Findings suggest that DRG systems could be enhanced either by the inclusion of patient-level variables, by the use of measures of clinical outcome or by improving cost and administrative information.

Diagnosis-Related Groups in Hand Surgery--a comparison of six European countries.

Diagnosis-Related Group (DRG) is a classification system, which groups patients according to their diagnosis and resource consumption. Common hand surgical diagnoses and procedures were processed using national DRG-groupers of six European countries. The upper thresholds of length of stay (LoS) are indicated for every country with the exception of Spain. The mean value in the series was 9.9 days for Germany, 4.5 days for Austria, 10.7 days for Italy, 9.7 days for Sweden and 9.4 days for the United Kingdom (UK). Germany and Austria also have lower thresholds of LoS and the average LoS.Multiple finger replantation presented the highest single case reimbursement in Germany, Austria and the UK (13,825 €, 10,576 € and 9,198 €). Scaphoid non-union had the highest single case reimbursement in Italy (2,676 €), flap coverage of wounds in Spain (5,506 €) and trapeziometacarpal arthritis in Sweden (5,350 €). The mean values for single case reimbursement were as follows: Germany 3,211 €, Austria 2,821 €, Italy 1,947 €, Spain 3,594 €, Sweden 2,403 € and the UK 3,253 €. Ten out of 19 cases showed the highest reimbursement in Spain, followed by the UK (5 cases), Sweden (2 cases), Germany and Austria (1 case each). Applying the case numbers of our clinic to the reimbursement system of each country, total proceeds would be 2.25 million € in Spain, 1.79 million € in Germany as well as the UK, 1.75 million € in Austria, 1.63 million € in Sweden and 1.22 million € in Italy. The consequences of international differences in efficiency and reimbursement are hard to assess as they are influenced by multiple factors that are seldom purely market-driven. However, the consideration of international data for benchmarking and refinement of national compensation systems should be a useful instrument.