Introduction to the EuroDRG project: main research objectives

Introduction to the EuroDRG project: main research objectives

18 July 2012 Introduction to the EuroDRG project: main research objectives 1

Reinhard Busse, Prof. Dr. med. MPH FFPHDepartment of Health Care Management, Berlin University of Technology

& European Observatory on Health Systems and Policies

on behalf of the EuroDRG team

A policy question in the 6th EU Framework Programme:

Why do costs of health services differ among EU countries atthe micro level?

How I got interested in DRGs (2002)

£5,000

£6,000

£7,000

£8,000

£9,000

NHS

2

£0

£1,000

£2,000

£3,000

£4,000

£5,000

Cataract Hip Knee

UK private

France

The first nine patients sent to

France by the English NHS

(not shown: the 40 journalists

who accompanied them)

Are these data realistic?

Are they representative?

How can the differences be explained?Introduction to the EuroDRG project: main research objectives18 July 2012

5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00

10000,00in €

Using 10 “vignettes” across countries

(with standardised description of patients)

E.g. Acute myocardial infarction

395,97

1025,76

1861,02

2465,32

2866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,8452733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

33Introduction to the EuroDRG project: main research objectives18 July 2012

Published in Health

Economics 2008; 17(S1)

5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00

10000,00in €Acute myocardial infarction

patient variables

medical and management

decision variables

gender, age,main diagnosis, other

diagnoses, severity

mix and intensity of procedures,

395,97

1025,76

1861,02

2465,32

2866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,8452733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

44

mix and intensity of procedures, technologies and human

resource use

e.g. size, teaching status; urbanity; wage level

structural variables on

hospital/ regional/

national level

Introduction to the EuroDRG project: main research objectives18 July 2012

5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00


patient variables

medical and management

decision variables

gender, age,main diagnosis, other

diagnoses, severity

mix and intensity of procedures,

Open question 1: How much do these variables contribute to cost

395,97

1025,76

1861,02

2465,32

2866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,8452733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

55

mix and intensity of procedures, technologies and human

resource use

e.g. size, teaching status; urbanity; wage level

structural variables on

hospital/ regional/

national level

these variables contribute to costvariation (and do DRG systems

take them into account)?


5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00

10000,00in €

none mixed “all”

Acute myocardial infarction:Hospitals performing PCI (PTCA/ Stenting)

395,97

1025,76

1861,02

2465,32

2866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,8452733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

> factor 4:value for money?


5916,455599,30

7450,22

5369,53

8282,36

6225,55

7616,89

9374,21

6000,00

7000,00

8000,00

9000,00


none mixed

Open question 2: If costs differ so much with treatment, what about

“all”

Acute myocardial infarction:Hospitals performing PCI (PTCA/ Stenting)

395,97

1025,76

1861,02

2465,32

2866,36

5013,64

308,88592,15

2236,40

2868,16

483,05

1415,79

2541,8452733,38

1181,531282,55

3720,88

4384,724161,15

0,00

1000,00

2000,00

3000,00

4000,00

5000,00

Hungary

(N=2)

Poland

(N=5)

Spain

(N=5)

Denmark

(N=3)

Germany

(N=13)

England

(N=3)

France

(N=3)

Netherlands

(N=6)

Italy

(N=5)

much with treatment, what aboutthe quality of care?


8000

10000

12000

Re

imb

urs

em

en

t (E

uro

s)

Hip implant

Hospitals in NL

0

2000

4000

6000

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Total cost (Euros)

Re

imb

urs

em

en

t (E

uro

s)

Denmark

England

France

Germany

Hungary

Italy

Netherlands

Poland

Spain

88Introduction to the EuroDRG project: main research objectives18 July 2012 8

8000

10000

12000

Re

imb

urs

em

en

t (E

uro

s)

Open question 3: Do costs differ even

Hip implant

0

2000

4000

6000

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Total cost (Euros)

Re

imb

urs

em

en

t (E

uro

s)

Denmark

England

France

Germany

Hungary

Italy

Netherlands

Poland

Spain

Open question 3: Do costs differ evenmore(and why) if we include

different patient characteristica?


SuomiFinland

Countries covered by EuroDRG project1018 July 2012

What did we do?

• Phase I – DRG system design and characteristics

How do DRG system in Europe work? Why and when implemented? How does patient classification work? Where do data come from? Uniform or regionally adapted? How often updated? Impact on efficiency and quality? …

• Phase II – empirical performance evaluation

• Phase III – conclusions

Conclusions for policy-makers within and beyond European countries …


18 July 2012 12Introduction to the EuroDRG project: main research objectives

What did we do?

• Phase I – DRG system design and characteristics

• Phase II – empirical performance evaluation

For 10 “episodes of care” cross-country comparisons of (1) actual classification, (2) reimbursement, (3) factors explaining cost variation,

DRG catalogues, DRG patient-leveldatabases, reimbursement lists …

empirical evaluations with patient-level data

(3) factors explaining cost variation, (4) cost-quality relationship

• Phase III – conclusions


with patient-level databases including costs/length-of-stay

The “episode of care“ approach

Why? Evaluation of hospital performance requires to look at a set of comparable/ adjustable patients � we chose all patients with a certain diagnosis and/ or procedure

Why not using DRGs directly? DRG classification differs across countries � to study effects we needed to define “meta-DRGs”

Selection criteria for episodes of care

• Relatively frequent (� we wanted to work with original patient • Relatively frequent (� we wanted to work with original patient data)

• Representing different medical specialties (internal medicine, surgery, obstetrics and gynaecology etc.)

• Involving diagnostic and/or therapeutic procedures (including the use of innovative technologies)

• Coding within and across countries deep enough to allow for analysis of differences


Finland - THL England - CHE Austria - MSIG Netherlands - iBMG Poland - NHF Spain - IMAS Germany - TUB Sweden - CPK

EoC and related questionsRecommended for inclusion?

(yes/no)

Recommended for inclusion?

(yes/no)


(yes/no)


(yes/no)

Can you differentiate the

following items?

(yes/no)

RemarksRecommended for inclusion?

(yes/no)


(yes/no)


(yes/no)


(yes/no)

1. Breast cancer

Types of carcinoma (invasive and not invasive) no NO - CANNOT IDENTIFY DISEASE STAGE, SO COMPARABILITY PROBLEMATIC

yes, however we should explicitly in- or exclude certain treatments.

We could have a clear picture of breast cancer.

Yes

ICD10

YES yes, but cannot identify disease stage

yes

Stages of the disease (TNM, IUCC …), grade of the disease (G1-G4)

No

Protein and gene expression status (oestrogen receptor (ER), progesterone receptor (PR) and HER2/neu proteins)

No

Types of treatment: surgery, radiation, hormone immune and chemotherapy

Yes

excluding hormone immuneTypes of surgery: tumourectomy, mastectomy - with or without lymph-adenectomy and reconstruction

Yes

ICD92. Colorectal cancer

Location of the cancer, i.e. in the colon (possibly further specified), rectum and caecum

no NO - CANNOT IDENTIFY DISEASE STAGE, SO COMPARABILITY PROBLEMATIC

yes, but a detailed definition is required We could have a clear picture of colorectal cancer. However, we can not identify patients who had both surgery and chemotherapy. Yes

ICD10

YES yes, but cannot identify disease stage

yes

Stages of the cancer (TNM, IUCC, Dukes classification …), grade of the disease (G1-G4)

No

Types of treatment: surgery, radiation, chemotherapy

Yes

ICD9 Extent of surgery (both within colon/ rectum and other organs)

Yes

ICD93. Diabetes mellitus

Types of diabetes (type 1 and type 2) yes,although is complicated

NO yes It is rather difficult to get a clear picture of diabetes mellitus, predominantly owing to the many departments involved and the inability to link them.

Yes

YES yes

yes

Reason for admission (e.g. hyperglycaemic or hypoglycaemic shock; other complications),

Yes

Procedures related to the main diagnosis diabetes (e.g. amputation)

Yes

4. Acute myocardial infarction (AMI)

Type of acute myocardial infarction (both ST-elevated MI [STEMI] and non-ST-elevated MI [NSTEMI])

yes YES yes We could have a clear picture of acute myocardial infarction, except when it comes to CABG procedures.

Yes

YES yes

yes

Treatment (PTCA, stent, CABG/bypass)

Yes

ICD95. Percutaneous coronary interventions (PCI)

Indications for PCI yes,requires exact definition of procedure codes in order to secure comparability between countries

YES yes We could have a clear picture of PCI procedures. However, the number of diagnosis-codes may turn out to be too extensive/ complex to work with.

Yes NO or maybe we think about redefining parameters of the episode

yes

yes

Treatment (PTCA, stent) YesICD9

Location of intervention (number of vessels treated, affected coronary artery, bifurcation …)

Yes

ICD9Details of stent (bare metal vs. drug-eluting; number of stents, affected coronary artery, type of drug on DES …)

Yes

ICD96. Coronary artery bypass graft surgery (CABG)

Indications for CABG yes,requires exact definition of procedure codes in order to secure comparability between countries

YES yes We could have a clear picture of CABG procedures. However, we can not distinguish the underlying diagnoses (such as acute myocardial infarction).

Yes NO or maybe we think about redefining parameters of the episode

yes, but some difficulties

Grafting of both types of blood vessels: arteries and veins

No

Type of surgery: with the usage of cardiopulmonary bypass or so-called ‘off-pump’ surgery

Selected episodes of care:

• Appendectomy

• Cholecystectomy

• AMI

• Bypass (CABG)

• Stroke

• Inguinal hernia

• Hip replacement

• Knee replacement

15

yes

called ‘off-pump’ surgery

Yes

7. Stroke

Cause (due to ischemia (thrombosis or embolism) or haemorrhage)

yes YES yes We could have a clear picture of stroke.

Yes

ICD10

YES yes

yes

Treatment settings (ICU, stroke unit or medical/ neurological ward) Yes

Rehabilitation within operating hospital or associated settings (vs. rehabilitation after transfer, i.e. after end of episode)

No

8. Community-acquired pneumonia

Hospital-acquired pneumonia (nosocomial) (e.g. by special code or ”present on admission“ code)

no NO yes It is rather difficult to get a clear picture of community-acquired pneumonia, because we can not distinguish between hospital and community-acquired pneumonia.

No

yes, but no information on type of antibiotics used for treatment

Treatment settings (ICU or medical ward)

No

Type of treatment (especially antibiotics)

No

9. Inguinal hernia repair

Type of inguinal hernia (bilateral – unilateral, direct – indirect) yes YES yes, should we define a minimal age? It is rather difficult to get a clear picture of inguinal hernia repair, because we can not distinguish between hernia femoralis and inguinalis. Yes

YES yes but not possible to identify direct/indirect

yes

Type of surgical repair (with or without graft or prosthesis implant)

Yes

Treatment setting (inpatient, outpatient)

Yes

inpatient only10. Appendectomy

Type of surgery (laparoscopic or open) yes YES yes We could have a clear picture of appendectomy.

Yes

YES yes

yes


Yes

inpatient only11. Cholecystectomy

Type of surgery (laparoscopic or open) yes YES yes It is rather difficult to get a clear picture of cholecystectomy. However, we could have a clear picture of cholecystitis.

Yes

YES yes

yes


Yes

inpatient only12. Hip replacement

Indication (osteoarthritis, other types of arthritis, protrusio acetabuli, avascular necrosis, hip fractures and benign and malignant bone tumours)

yes YES yes We could have a clear picture of hip replacement. However, we can not always distinguish the underlying diagnoses.

Yes

ICD10

YES yes, but difficult to know numbers for rehabilitation

yes

Type of replacement (e.g. hemiprosthesis, total endoprosthesis, resurfacing)

Yes

Type of surgery (cemented, cementless and hybrid prosthesis)

Yes

First replacement vs. revision Yes

Rehabilitation within operating hospital or associated settings (vs. rehabilitation after transfer, i.e. after end of episode)

No

• Knee replacement

• Breast cancer

• Childbirth

Dropped:

• Colorectal cancer

• Diabetes

• Com.-acq. Pneumonia

• Urolithiasis

• Traumatic brain injury


Patient-level data bases used (topics 3 & 4)


For further reading (topic 3)


EuroDRG project partners

Austria Department for Medical Statistics, Informatics and Health Economics, Innsbruck Medical University

England/ UK Centre for Health Economics, University of York

Estonia PRAXIS Center for Policy Studies, Tallinn

Europe European Health Management Association, Brussels

Finland National Institute for Health and Welfare , Helsinki

France École des hautes études en santé publique, Rennes &Institut de recherche et documentation en économie de la santé, Paris

Germany Department of Health Care Management, Technische Universität Berlin

Ireland Economic and Social Research Institute, Dublin

Netherlands Institute for Health Policy & Management, Erasmus Universitair Medisch Centrum Rotterdam

Poland National Health Fund, Warsaw

Portugal Avisory board member Céu Mateus

Spain Institut Municipal d’Assistència Sanitària, Barcelona

Sweden Centre for Patient Classification, National Board of Health and Welfare, Stockholm


EuroDRG consortium members

Picture: 22nd January 2010, Paris


Introduction to the EuroDRG project: main research objectives

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