DRG as a quality indicator
4th Nordic Casemix Conference
3-4th June 2010
Paasitorni, Helsinki, Finland
Lisbeth Serdén
National Board of Health and Welfare
General
• There are other aspects of quality in health care
then treatment policy and medical outcomes
• DRG systems contribution to quality
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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 and 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/publikationer2010/2010-437 http://www.socialstyrelsen.se/publikationer2009/2009126-144
Quality 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 processes
Efficiency in health care – cardiac care
Improvement in coding
• Introduction of DRG-systems leads to
improvement in coding. Just the use of DRGsystems 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 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
supports quality
• DRG gives the possibility as a part of
reimbursement systems to reward good quality
with higher or extra payment
International 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 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
medical care 2008
Cost per DRG point –specialised
medical 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 2008
Västerbotten
Jönköping
Halland
Norrbotten
Uppsala
Skåne
Stockholm
Västra Götaland
Sweden
Västmanland
Kronoberg
Östergötland
Örebro
Sörmland
Kalmar
Gävleborg
Västernorrland
Värmland
Dalarna
Jämtland
Blekinge
Gotland
0
0.5
1
1.5
2
2.5
3
3.5
Diagnoses 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 incorrect
coding, DRG 468, DRG 469, DRG 470 and
DRG 477
Halland
Jönköping
Uppsala
Norrbotten
Örebro
Dalarna
Västerbotten
Jämtland
Skåne
Kalmar
Östergötland
Gävleborg
Sweden
Stockholm
Gotland
Sörmland
Värmland
Västra Götaland
Västmanland
Kronoberg
Blekinge
Västernorrland
0.0%
2007
2008
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
The DRG system built-in logic on
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
• Indicator on incorrect coding
• Regional differences between 0.2 to 2.8 percent
• The main reason is ‘primary diagnosis is missing’
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
to DRG 143 Chest pain, 2008
Norrbotten
Blekinge
Västra Götaland
Skåne
Halland
Västerbotten
Stockholm
Sweden
Östergötland
Värmland
Gotland
Angina pectoris
Örebro
Chest pains
Dalarna
Jönköping
Uppsala
Jämtland
Västmanland
Gävleborg
Västernorrland
Kalmar
Sörmland
Kronoberg
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
DRG 140 Angina pectoris compared
to 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
disease compared to DRG 96 and DRG 97
Bronchitis & asthma, age > 17 w cc/wo cc
Skåne
Östergötland
Västernorrland
Sörmland
Gävleborg
Örebro
Västmanland
Stockholm
Kalmar
Sweden
Värmland
DRG 88
Västra Götaland
DRG 96-97
Kronoberg
Norrbotten
Dalarna
Jönköping
Uppsala
Blekinge
Halland
Jämtland
Gotland
Västerbotten
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
DRG 88 Chronic obstructive pulmonary
disease compared to DRG 96 and DRG 97
Bronchitis & 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
with and without complication
Västerbotten
Jönköping
Skåne
Stockholm
Uppsala
Norrbotten
Halland
Västmanland
Västra Götaland
Sweden
Kalmar
Örebro
Östergötland
Sörmland
Kronoberg
Gävle borg
Blekinge
Västernorrland
Värmland
Dalarna
Gotland
Jämtland
0%
5%
10 %
15 %
20 %
25 %
30 %
35 %
40 %
DRGs 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
major joint, age > 17, w cc compared to
DRG 211 wo cc
Stockholm
Norrbotten
Västerbotten
Jönköping
Örebro
Skåne
Uppsala
Halland
Västra Götaland
Sweden
Kalmar
DRG 210
Västernorrland
DRG 211
Dalarna
Gävleborg
Kronoberg
Västmanland
Östergötland
Sörmland
Blekinge
Gotland
Värmland
Jämtland
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
DRG 210 Hip & femur procedures except
major joint, age > 17, w cc compared to
DRG 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 14B Stroke wo cc
Halland
Stockholm
Västra Götaland
Västerbotten
Skåne
Sweden
Kronoberg
Örebro
Jönköping
Jämtland
Kalmar
Västernorrland
Norrbotten
Gävleborg
Östergötland
Uppsala
Västmanland
Sörmland
Värmland
Dalarna
Gotland
Blekinge
014A
014B
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
DRG 14A Stroke w cc compared to
DRG 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
Swedish 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
Conclusions
• 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 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
Stroke wo cc compared to DRG 15
TIA
Västernorrland
Jämtland
Östergötland
Sörmland
Kronoberg
Uppsala
Dalarna
Gävleborg
Stockholm
Blekinge
Sweden
Stroke
Västra Götaland
TIA
Västmanland
Kalmar
Örebro
Värmland
Skåne
Jönköping
Norrbotten
Västerbotten
Halland
Gotland
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
DRG 14A Stroke w cc and DRG 14B
Stroke wo cc compared to DRG 15
TIA
• 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