Caroline Delo

Analysis of the variability of nursing care by pathology in a sample of nine Belgian hospitals

In 2010, a Belgian study [1] explored the feasibility of introducing all-inclusive case-based payments for Belgian hospitals. In this kind of financing system, hospital services and patient mix are described in a simplified way through Diagnosis Related Groups (DRGs). A tariff is fixed in advance for each DRG. DRGs are groups of patients based on economic and clinical homogeneity. Clinical homogeneity is achieved on the basis of medical diagnosis, co-morbidities, medical procedures, complications, etc. Economic homogeneity is achieved by using, first of all, the length of stay (LOS) or cost (or charges) of hospitalization as a classification criterion. As soon as DRGs were introduced, most nursing research revealed that DRGs were not very amenable to homogeneous integration with nursing care. DRGs only explained 20% to 40% of the variability in nursing care. Coefficients of variation for nursing care per DRG have been reported as varying from 0,22 to 2,56 [2-5]. This is the reason why some researchers try to refine DRG classification into classes of nursing cost per DRG [6]. However, it is difficult to find recent data that deals with this. The objectives of this study are to: • Discover if nursing activity is homogeneous by DRG and severity of illness. • Evaluate the correlation between LOS of patients and nursing activity per patient.

Variability of nursing care by APR-DRG and by severity of illness in a sample of nine Belgian hospitals.

BackgroundAs soon as Diagnosis related Groups (DRG) were introduced in many hospital financing systems, most nursing research revealed that DRG were not very homogeneous with regard to nursing care. However, few studies are based on All Patient refined Diagnosis related Groups (APR-DRGs) and few of them use recent data. Objectives of this study are: (1) to evaluate if nursing activity is homogeneous by APR-DRG and by severity of illness (SOI) (2) to evaluate the outlier’s rate associated with the nursing activity and (3) to compare nursing cost homogeneity per DRG and SOI.MethodsStudy done in 9 Belgian hospitals on a selection of APR-DRG with more than 30 patients (7 638 inpatient stays). The evaluation of the homogeneity is based on coefficients of variation (CV). The 75th percentile + 1.5 × inter-quartile range was used to select high outliers. 25th percentile −1.5 × inter-quartile range was used to select low outliers. Nursing costs per ward were distributed on inpatient stays of each ward following two techniques (the LOS vs. the number of nursing care minutes per stay).ResultsThe homogeneity of LOS by DRG and by SOI is relatively good (CV: 0.56). The homogeneity of the nursing activity by DRG is less good (CVs between 0.36 and 1.54) and is influenced by nursing activity outliers (high outliers’ rate: 5.19%, low outliers’ rate: 0.14%). The outlier’s rate varies according to the studied variable. The high outliers’ rate is higher for nursing activity than for LOS. The homogeneity of nursing costs is higher when costs are based on the LOS of patients than when based on minutes of nursing care (CVs between 0.26 and 1.46 for nursing costs based on LOS and between 0.49 and 2.04 for nursing costs based on minutes of nursing care).ConclusionsIt is essential that the calculation of nursing cost by stay and by DRG for hospital financing purposes was based on nursing activity data, that more reflect resources used in wards, and not on LOS data. The only way to obtain this information is the generalization of computerized nursing files.

Costs of disposable material in the operating room do not show high correlation with surgical time: Implications for hospital payment.

OBJECTIVES The objectives of this study are to analyze the variation of the surgical time and of disposable costs per surgical procedure and to analyze the association between disposable costs and the surgical time. METHODS The registration of data was done in an operating room of a 419 bed general hospital, over a period of three months (n = 1556 surgical procedures). Disposable material per procedure used was recorded through a barcode scanning method. RESULTS The average cost (standard deviation) of disposable material is €183.66 (€183.44). The mean surgical time (standard deviation) is 96 min (63). Results have shown that the homogeneity of operating time and DM costs was quite good per surgical procedure. The correlation between the surgical time and DM costs is not high (r = 0.65). CONCLUSIONS In a context of Diagnosis Related Group (DRG) based hospital payment, it is important that costs information systems are able to precisely calculate costs per case. Our results show that the correlation between surgical time and costs of disposable materials is not good. Therefore, empirical data or itemized lists should be used instead of surgical time as a cost driver for the allocation of costs of disposable materials to patients.

Comparison of cost-weights scales methodologies in the perspective of a financing system based on pathologies

ObjectivesObjectives of this article are to evaluate the possibility to create a CW scale by pathology on the basis of cost data from Belgian hospitals, to compare several methodologies to create this CW scale, and to evaluate the financial impact of a modification of the financing system on hospitals’ income.MethodsCW scales were elaborated according to various methodologies in order to isolate the scale allowing the most adequate financing system, i.e. approaching the real costs as much as possible. Twelve scales were created. They vary according to the type of data used, according to DRGs and severities of illness included within the scale, and according to the variable used in order to isolate outliers.ResultsFor a similar case-mix, Hospitals H2 and H5 would see their financing increased through a prospective system based on the selected CW scale (No. 6). This modification would generate a reduction in financing going from −1 to −9% according to hospitals.ConclusionsThe cost database created made it possible to create a CW scale according to a technique which could constitute the first step of a PPS if advantages of a such financing system were established. In the Belgian context, it would be probably judicious to envisage regional databases allowing diversified methodological approaches whose results would be confronted, discussed, and coordinated at the federal level.