Utilization and outcome in the medical patient referred to surgery.

The objective of this study was to test the hypothesis that hospitalized patients referred to a general surgical service from a medical service for a surgical procedure would have higher hospital costs and longer lengths of stay per diagnosis-related group (DRG) than patients admitted directly to the general surgical service. Hospital costs by DRG, exclusive of physician's fees, were analyzed for all adult general surgical admissions treated at our hospital from January 1, 1985 to March 31, 1986 (3,028 patients) to yield a population of patients in those DRGs with patients referred to general surgery from medicine (1,495 patients). Patients within each DRG were then disaggregated by either direct admission to general surgery (1,412 patients) or referral to the general surgical service from the medical service (83 patients). Mean cost per patient was 146.5 percent higher for referral patients than for direct admission patients, as was the total length of stay. Mortality was higher for referral patients than for direct admission patients. Factors analyzed which contributed to this greater resource utilization and higher mortality were (1) a greater severity of illness, (2) higher diagnostic costs, and (3) delays in diagnosis or treatment. The DRG payment for referral patients also produced a substantial deficit for the hospital, whereas direct admission patients produced a profit of +1,105,596. This data suggests that direct admission to the surgical service of patients likely to need surgery might lower their hospital costs and improve the quality of their care.

Automated screening for quality of care in the hospital--a feasibility study.

A feasibility study for computer-based quality screening was carried on 497 clinical cases. Rule-directed audit criteria were used. Discharge summaries were analyzed in an effort to detect possible quality problems. The charts of the same cases were also screened by nurses, and the suspected cases of both process es were further reviewed by physicians. The computer-based text analysis compared favorably with the screening by nurses, and showed a rather low false negative rate. The objectives of substantiating the discharge summary as a valid source document for generic quality screening was demonstrated. In addition the economy and feasibility of computer based text analysis and interpretation was proven. Finally the applicability of algorithmic rules in detecting clinical quality indicators showed great promise and presents an area of further research. Thus the feasibility study was highly successful. The potential of computer-based care quality assessment is discussed.

Diagnosis related groups and the transfer of general surgical patients between hospitals.

This study tested the hypothesis that financial risk would be generated by surgical patients transferred to our hospital from other acute care hospitals under diagnosis related group (DRG) reimbursement. Hospital costs by DRG (exclusive of physician fees) were analyzed for all adult general surgical patients transferred to our medical center from another acute care hospital between Jan 1, 1985, and Dec 31, 1986. Transferred patients (n = 97) had significantly higher resource utilization (ie, hospital costs) than nontransferred patients (n = 2976) within the same surgical DRGs as follows: total mean cost per patient, $17,348 vs $9,460; mean length of stay 21.4 days vs 10.9 days; mean laboratory cost per patient, $1849 vs $975; and mean radiologic cost per patient, $794 vs $397. Transferred patients generated a yearly deficit of $238,717 ($4922 loss per patient) for the hospital, whereas other patients within the same DRGs generated a profit of $727,632 ($489 profit per patient). These data support the hypothesis that DRG reimbursement will provide a financial disincentive for teaching hospitals to accept surgical transfer patients from other acute care hospitals, thus potentially decreasing the access of care for the complexly ill surgical patient.

The identifier concept: clinical variables to manage costs for surgical patients.

Previous studies at Long Island Jewish Medical Center had shown that certain clinical variables (identifiers) would differentiate hospital charges within surgical diagnosis-related groups (DRGs). This current project demonstrated that the clinical variables of mode of admission (emergency versus nonemergency), blood transfusion, and surgical intensive care unit admission could stratify both differences in severity of illness and charges for patients in general surgical DRGs. These findings suggest that these three identifiers may be useful to physicians and hospital administrators in evaluating surgical patients for differences in resource consumption during their hospitalization, for better management of hospital-based inpatient costs.

Mode of admission and cost for surgical DRGs.

The purpose of this study was to confirm the hypothesis that emergency department admissions were more expensive than their nonemergency counterparts per diagnosis-related group (DRG) and to see if this characteristic was displayed across many hospitals. All surgical admissions (N = 39,682) to the 11 acute-care hospitals of the New York City Health and Hospitals Corporation were analyzed during an 18-month period to yield a study population (N = 26,569) of matched DRG subgroups (ED vs nonED) at each hospital of at least five patients per variable for that particular DRG. A cost-per-patient analysis was conducted for each admission. Total costs for the study population were $163,360,636. A total of 75.8% of surgical admissions (N = 20,143) were admitted in DRGs in which ED admissions were more costly than their nonED-matched counterparts. The following was the trend in percentage of total specialty admissions in DRGs in which ED admissions were more costly than nonED admissions: urology (88.4%); ear, nose, and throat (86.2%); general and vascular (80.1%); cardiothoracic (78.0%); orthopedics (75.6%); plastic surgery (62.1%); neurosurgery (60.5%); and ophthalmology (46.0%). Route of admission (ED vs nonED) was an identifier of higher-cost patients per DRG across hospitals in a large public hospital system. These data demonstrate that hospitals with substantial numbers of surgical ED admissions may face significant financial risk under DRG reimbursement, and suggests that the DRG system does not adequately compensate hospitals for the higher cost of the emergency surgical admission.

Source of admission and cost: public hospitals face financial risk.

We studied all admissions to the 11 acute care hospitals of the New York City Health and Hospitals Corporation (April 1983-September 1984) matching emergency room (ER) admitted diagnostic related group (DRG) subgroups in each hospital with at least five non-ER admitted patients (N = 222,961). Mean cost per ER patient ($8,385) was greater than non-ER mean cost per patient ($4,386) for Medicare and non-Medicare. Our data suggest that public hospitals with a high proportion of ER admissions may be at a financial disadvantage under DRG reimbursement.