A new logic for co-morbidity and complications in Sweden – NordDRG-CC Mona Heurgren Head of Unit Unit for development of Quality and Efficiency Studies The National Board of Health and Welfare Sweden Agenda • The scoop and benefits of case-mix adjustments • Background and acknowledgements of the project • Goals and Method • Results • Areas of use • The use in Sweden 2012 and 2013 The scoop of case-mix adjustments • The idea of case-mix is to adjust for differences in severity of illness, medical practice or risk for mortality in a defined group of patients/inhabitants or other populations • The current NordDRG system adjusts primly for severity of illness and medical practice per case for patients treated in hospitals • International development of case-mix systems suggests that more levels for co-morbidity and complications should be introduced to improve performance of the system s Main reasons to improve NordDRGs ability to adjust for case-mix • To improve how to describe performance with DRGs (ex to be used for productivity and efficiency studies) • A better adjustment for case-mix when comparing hospital performance in health care (Benchmarking) • To improve the analysis of differences in case-mix at hospitals • To improve how to describe hospital processes and performance • To develop better prospective payment systems and budgeting methods within hospitals • To achieve a higher acceptance for DRGs in the professional community Background • During the last decade there has been an ongoing discussion about the need to improve the DRGs ability to describe co-morbidity and/or complications • Several countries have already done the development work and changes in their DRGsystems (US, Canada, Australia) • The coding of bi-diagnoses in the Sweden has not had sufficient quality for the development work. The latest years the coding in Sweden has improved significantly (average 2.6 per case). Acknowledgements • The project is financed by the Swedish Ministry of Heath and Welfare • The project group represents a mix of different competences. Economist, physicians, statistician and medical secretary. – Per Sjöli Project leader – Mona Heurgren Project owner – Mats Fernström Medical advisor – Ralph Dahlgren Medical advisor – Gunnar Henriksson Medical advisor – Liselotte Säll Secretary – Åke Karlsson Statistician – Anders Jacobsson Statistician – Martti Virtanen Technical and medical advisor The aim of the Project • To develop a new logic within the NordDRGsystem for co-morbidity and/or complications (CC-logic) • To produce logic tables and software products for Sweden to be used in 2012 Method • To learn from others, there has been no possibility to develop a total new system – would require both more data and resources • Solution – To use the method of the Federal government DRG-office (CMS) in the US, the MS (Medicare Severity) -DRG system – The logic can be found at the internet • Development work - To translate ICD9CM to ICD10 diagnoses – To verify bi-diagnoses significance with volume and cost data – Manually grouping and validation of the new logic from both a medical, statistical and economical perspective with respect to the criteria's for changing the NordDRG system – Production of definition tables and databases Criteria's for changing DRGs • The variation (cv) in the new groups should decrease with at least 5% • The new group should embrace at least 3% of the original volume • The average cost difference between the new group and the old group should at least be 20% • The overall performance in the system should improve or the change must at least not have a negative impact Results NordDRG-CC • A new logic is developed, a production version for 2012 will be available in November 2011 • NordDRG-CC is decided to be de only version in Sweden 2013 • The new logic means mainly more groups for comorbidity and/or complication cases and a change of the age groups (1-17 years) • New levels: No CC/CC/MCC (Major CC) or groups that are un-splitted (OBS they can be very complicated groups!) NordDRG-CC • About 750 groups in somatic inpatient care • In Sweden there is an additional of 400 groups for outpatient care • Fewer groups for children (0-17 years) • No change from the current system for neonatal care, psychiatry, rehabilitation and outpatient care • New codes and enumeration Major small & large bowel procedures , DRG 148 o 149 CC-grupperare NordDRG 2010 no CC No: 3 186 Cost:96 628 SEK CV:41% 149, no CC No: 3 368 Cost:95 281 SEK CV:45% All 148/149 No: 6 164 Cost: 117 528 SEK CV:59% CC No:6 635 Cost:124 731 SEK CV:51% 148, CC No: 2 907 Cost:150 757 SEK CV:60% MCC No: 1 212 Cost:190 957 SEK CV:59% MCD-structure Letter A B C D E F G H J K L M N O P Q R R S T U V W U X Y Z MDC 01 02 03 04 05 06 07 08 09 30 10 11 12 13 14 15 16 17 18 19 21 22 23 24 40 50 99 Sjukdomar i nervsystemet Sjukdomar i öga och närliggande organ Sjukdomar i öra, näsa, mun och hals Andningsorganens sj ukdomar Ci rkulationsorganens sjukd omar Matsmältningsorganens sjukdomar Sjukdomar i lever, gallväga r och bukspottkörtel Sjukdomar i muskler, skelett och bindväv Sjukdomar i hud och underhud Bröstkörtelsjukdomar Hormonella sjukdoma r, ämnesomsättnings- och näringssjukdomar Sjukdomar i njure och urinvägar Sjukdomar i manliga könso rg an Sjukdomar i kvinnliga könsorgan Gravi ditet, förlossning och barnsängstid Nyfödda och vissa perinatala tillstånd Blodsjukdomar och immunol ogiska rubbningar Sjukdomar i blodbildande organ och icke specifika tumörer Infektions- och parasitsjukdomar inklusive HIV Psykiska sjukdomar, beteendestörningar och alkohol- e ller drogberoende Skador, förgiftningar och to xiska effekter Brännskador Andra och ospecificerade hälsoproblem Multipelt trauma utom ytli ga skador och sårskador MDC-övergripande problem i öppenvård Vårdgivarberoende grupper i öppe nvård Ospecifik eller felaktig i nformation The letter is the first position in the DRG-code DRG-codes - CC L e tte r In/o ut pat A C E N O P Q X Y Z IN IN IN IN O UT O UT O UT O UT O UT O UT C C -s p lit MC CC No No No CC No No No No T yp e o f v is i t C CC sp l it sp l it CC sp l it sp l it sp l it S i n g l e v is it S i n g l e v is it S i n g l e v is it T e a m vi si t G r o u p v is it T e le p h o n e co n su lta tio n s Example: Code: DRG-text: A03A Intercraniell surgery for tumor, MCC E07E Coronar bypass, No CC H10P Major knee surgery, CC NordDRG (001A) (107A/107C) (222P) Advantages so far • Describes case-mix better • Better description of the most sick patients • Reduced variance in most groups; i.e a more cost homogenic system – big differences between the levels • Insensitive to better primary coding • Follows international development trends • Higher acceptance within the profession • More information within the coding system • Better outlier information Differences in average costs for splited DRGs Factor 2,50 MCC Factor 1,42 CC No CC 0 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 1,8 2 2,2 2,4 2,6 2,8 Distribution CC-level per age group 38 CC distribution per County 01 Stockholm 03 Uppsala 04 Södermanland 05 Östergötland 06 Jönköping 07 Kronoberg 08 Kalmar 09 Gotland 10 Blekinge 12 Skåne BAS 13 Halland CC 14 Västra Götaland MCC 17 Värmland 18 Örebro 19 Västmanland 20 Dalarna 21 Gävleborg 22 Västernorrland 23 Jämtland 24 Västerbotten 25 Norrbotten 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% Other findings – CC versus NordDRG • DRG-points get lower for private selected care • DRG-points get higher for deceased patients and for acute care patients • DRG-points get slightly higher for University hospitals but not mutch • Small differences in DRG-points on county level and for most hospitals • Better overall explenatory value Disadvantages? • Initial administration when introducing a new system • Change of codes and weight lists mean more work to hospitals and counties initially • A need to develop information activities from national level and form local levels • More groups will produce some more annual administration and maybe when calculation weights NordDRG CC - the future • The project will end this year. • The Region of Västra Götaland, County of Halland, The County of Uppsala and the Southern Region in Sweden are going to use the CC-version 2012. All counties are going to use the system Sweden in 2013. • National weight list has been developed and published on the web-site. • Some adjustments of NordDRG CC will be performed during next year. • The other Nordic countries? Web-adress: www.socialstyrelsen.se