Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2861pmid: 22815107
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2837pmid: 22815108
ABSTRACT We set out an analytical strategy to examine variations in resource use, whether cost or length of stay, of patients hospitalised with different conditions. The methods are designed to evaluate (i) how well diagnosis‐related groups (DRGs) capture variation in resource use relative to other patient characteristics and (ii) what influence the hospital has on their resource use. In a first step, we examine the influence of variables that describe each individual patient, including the DRG to which the patients are assigned and a range of personal and treatment‐related characteristics. In a second step, we explore the influence that hospitals have on the average cost or length of stay of their patients, purged of the influence of the variables accounted for in the first stage. We provide a rationale for the variables used in both stages of the analysis and detail how each is defined. The analytical strategy allows us (i) to identify those factors that explain variation in resource use across patients, (ii) to assess the explanatory power of DRGs relative to other patient and treatment characteristics and (iii) to assess relative hospital performance in managing resources and the characteristics of hospitals that explain this performance. Copyright © 2012 John Wiley & Sons, Ltd.
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2840pmid: 22815109
SUMMARY 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. Copyright © 2012 John Wiley & Sons, Ltd.
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2836pmid: 22815110
ABSTRACT Appendectomy is a common and relatively simple procedure to remove an inflamed appendix, but the rate of appendectomy varies widely across Europe. This paper investigates factors that explain differences in resource use for appendectomy. We analysed 106 929 appendectomy patients treated in 939 hospitals in 10 European countries. In stage 1, we tested the performance of three models in explaining variation in the (log of) cost of the inpatient stay (seven countries) or length of stay (three countries). The first model used only the diagnosis‐related groups (DRGs) to which patients were coded, the second model used a core set of general patient‐level and appendectomy‐specific variables, and the third model combined both sets of variables. In stage two, we investigated hospital‐level variation. In classifying appendectomy patients, most DRG systems take account of complex diagnoses and comorbidities but use different numbers of DRGs (range: 2 to 8). The capacity of DRGs and patient‐level variables to explain patient‐level cost variation ranges from 34% in Spain to over 60% in England and France. All DRG systems can make better use of administrative data such as the patient's age, diagnoses and procedures, and all countries have outlying hospitals that could improve their management of resources for appendectomy. Copyright © 2012 John Wiley & Sons, Ltd.
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2832pmid: 22815111
ABSTRACT We analysed patient‐level data (n = 72 235) from 563 hospitals in 10 European countries to assess the ability of national diagnosis‐related group (DRG) systems to account for patient‐level variation in cost or lengths of stay of breast cancer surgery patients against a standard set of patient characteristics, treatment and quality variables. We find that European DRG systems use very different types of classification variables and numbers of DRGs (range: 3–7) to classify these patients. In 6 of 10 countries, the set of patient characteristics, treatment and quality variables, which we were able to define across countries, perform better than the set of national DRGs in accounting for patient‐level variation in resource consumption. Moreover, there appear to be factors that are consistently significant determinants of cost/length of stay of breast cancer surgery cases but are not, or at least not fully, considered in European DRG systems. Our results therefore raise concerns as to whether all systems rely on the most appropriate classification variables. In several countries, policymakers should reevaluate the appropriateness of their DRG algorithm for breast cancer surgery and of specific DRG weights. Copyright © 2012 John Wiley & Sons, Ltd.
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2835pmid: 22815112
ABSTRACT Childbirth is one of the main causes of hospitalisation for women, accounting for about 5% of hospital activity in most Organisation for Economic Co‐operation and Development countries. We analysed the factors that explain variations in resource use for child delivery in ten European countries. We compared the performance of three models for explaining the variations in resource use (log cost or length of inpatient stay) at patient and hospital level. The first model used only the DRGs to which child deliveries were coded (MD), the second used a set of ‘patient‐level’ and delivery specific explanatory variables (MP), and the third model combined both sets of variables (MF). Countries vary both in the number of DRGs and the criteria used to classify cases of child delivery (range: 3–8) and in the percentage of deliveries classified as ‘delivery without complication’ (range: 53–90%). The capacity of DRGs and patient level variables to explain cost variation for child birth ranges from 48% in Sweden to over 70% in Spain. There is room for improving current DRG classification in most countries, but this does not necessary imply multiplying the groups and/or complicating criteria. Countries with a higher number of DRGs do not always perform better. Copyright © 2012 John Wiley & Sons, Ltd.
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2833pmid: 22815113
ABSTRACT Cholecystectomy is the surgical removal of the gallbladder. It is the most common method for treating symptomatic gallstones. Despite the existence of well‐established treatment guidelines, the rate of cholecystectomy varies widely across Europe. We analyse patients in 10 countries that had undergone surgery for the treatment of symptomatic gallstones. We test the performance of three models in explaining variation in the (log of) cost of the inpatient stay (seven countries) or length of stay (three countries). The first model includes only the diagnosis‐related group (DRG) variables to which cholecystectomy patients were coded (MD), the second uses a core set of patient characteristics and episode‐specific explanatory variables (MP), and finally, the third model combines both sets of variables (MF). Countries vary both in the number of DRGs used to classify cholecystectomy patients (range: 2–8), and in the percentage of patients covered by a single DRG (range: 50%–92%). The ability of combining both DRGs and patient level variables to explain cost variation among patients ranges from 58% in Spain to over 81% in Finland. The comparison of models' performance suggests that incorporating relevant patient characteristics may significantly improve DRG systems. Copyright © 2012 John Wiley & Sons, Ltd.
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2842pmid: 22815114
ABSTRACT We analyse variations in cost or length of stay (LoS) for 66 587 patients from 10 European countries receiving a coronary artery bypass graft (CABG) procedure. In five of these countries, variations in cost are analysed using log‐linear models. In the other five countries, negative binomial regression models are used to explore variations in LoS. We compare how well each country's diagnosis‐related group (DRG) system and a set of patient‐level characteristics explain these variations. The most important explanatory factors are the total number of diagnoses and procedures, although no clear effects are evident for our CABG‐specific diagnostic and procedural variables. Wound infections significantly increase LoS and costs in most countries. There is no evidence that countries using larger numbers of DRGs to group CABG patients are better at explaining variations in cost or LoS. However, refinements to the construction of DRGs to group CABG patients might recognise first and subsequent CABGs or other specific surgical procedures, such as multiple valve repair. Copyright © 2012 John Wiley & Sons, Ltd.
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2839pmid: 22815115
ABSTRACT By classifying hospital output into groups of patients with similar clinical characteristics and resource requirements, diagnosis‐related groups (DRGs) are designed to be highly correlated with resource utilisation. Using a two‐stage approach to control for variation within and between hospitals, we examine the ability of the diverse DRG systems in 10 European countries to explain variability in resource utilisation (costs or length of stay, LoS) for hospital patients undergoing surgical repair of inguinal hernia. Our national regression results suggest that DRGs are statistically significant in explaining cost/LoS variation in the absence of any other regressors and generally remain so in most countries when patient‐level characteristics are added to the model. However patient‐level characteristics, including those used in DRG assignment, are usually also statistically significant. In nine countries, where the number of relevant DRGs ranges from two (Poland) to seven (France), the inclusion of patient‐level characteristics substantially improves model goodness‐of‐fit compared with that attained with DRGs alone. Only in Sweden is the converse true. If our analysis raises some concerns over the adequacy of DRGs to explain cost/LoS variation in inguinal hernia repair in nine of the 10 European countries, further research is required to consider whether future enhancements may be necessary. Copyright © 2012 John Wiley & Sons, Ltd.
Busse, Reinhard; Geissler, Alexander; Mason, Anne; Or, Zeynep; Scheller‐Kreinsen, David; Street, Andrew
doi: 10.1002/hec.2848pmid: 22815116
ABSTRACT This paper assesses the variations in costs and length of stay for hip replacement cases in Austria, England, Estonia, Finland, France, Germany, Ireland, Poland, Spain and Sweden and examines the ability of national diagnosis‐related group (DRG) systems to explain the variation in resource use against a set of patient characteristic and treatment specific variables. In total, 195 810 cases clustered in 712 hospitals were analyzed using OLS fixed effects models for cost data (n = 125 698) and negative binominal models for length‐of‐stay data (n = 70 112). The number of DRGs differs widely across the 10 European countries (range: 2–14). Underlying this wide range is a different use of classification variables, especially secondary diagnoses and treatment options are considered to a different extent. In six countries, a standard set of patient characteristics and treatment variables explain the variation in costs or length of stay better than the DRG variables. This raises questions about the adequacy of the countries' DRG system or the lack of specific criteria, which could be used as classification variables. Copyright © 2012 John Wiley & Sons, Ltd.
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