Magali Pirson

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.

What can we learn from international comparisons of costs by DRG

ObjectivesThe objective of this study was to compare costs data by diagnosis related group (DRG) between Belgium and Switzerland. Our hypotheses were that differences between countries can probably be explained by methodological differences in cost calculations, by differences in medical practices and by differences in cost structures within the two countries.MethodsClassifications of DRG used in the two countries differ (AP-DRGs version 1.7 in Switzerland and APR-DRGs version 15.0 in Belgium). The first step of this study was to transform Belgian summaries into Swiss AP-DRGs. Belgian and Swiss data were calculated with a clinical costing methodology (full costing). Belgian and Swiss costs were converted into US

Predictors of costs from the hospital perspective of primary pulmonary embolism

PPP (purchasing power parity) in order to neutralize differences in purchasing power between countries.ResultsThe results of this study showed higher costs in Switzerland despite standardization of cost data according to PPP. The difference is not explained by the case-mix index because this was similar for inliers between the two countries. The length of stay (LOS) was also quite similar for inliers between the two countries. The case-mix index was, however, higher for high outliers in Belgium, as reflected in a higher LOS for these patients. Higher costs in Switzerland are thus probably explained mainly by the higher number of agency staff by service in this country or because of differences in medical practices.ConclusionsIt is possible to make international comparisons but only if there is standardization of the case-mix between countries and only if comparable accountancy methodologies are used. Harmonization of DRGs groups, nomenclature and accountancy is thus required.

Prospective casemix-based funding, analysis and financial impact of cost outliers in all-patient refined diagnosis related groups in three Belgian general hospitals.

The objective of this study was to estimate the total hospital cost per patient admitted through the emergency department with a primary diagnosis of pulmonary embolism (PE), and to identify the main components and predictors of costs. Actual costs of care of 652 consecutive patients hospitalised in 10 general hospitals in Belgium, including 31 outlier patients in terms of length of stay (4.8%), were obtained by aggregating all cost components contributing to care of each patient. In both inlier and outlier patients, the mean total cost per patient increased linearly with the degree of severity of illness classes related to the All Patient Refined Diagnosis Related Group (p<0.0001). Medical procedures, nursing activities and hospitalisation accommodation were the main cost components. We identified six independent predictors of costs in inliers: age group, chronic pulmonary heart disease, heart failure, admission to intensive care unit, initial thrombolysis treatment and type of hospital. There was a statistically significant linear trend between age groups and costs (p<0.0001). An increasing burden of comorbid illness was strongly associated with increasing actual cost for caring hospitalised patients for PE. Increasing age was associated with an increase in all main cost components. Increased burden of comorbid illness is associated with increased cost of care for pulmonary embolism patients http://ow.ly/RSTPY

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

This study examined the impact of cost outliers in term of hospital resources consumption, the financial impact of the outliers under the Belgium casemix-based system, and the validity of two “proxies” for costs: length of stay and charges. The cost of all hospital stays at three Belgian general hospitals were calculated for the year 2001. High resource use outliers were selected according to the following rule: 75th percentile +1.5 ×inter-quartile range. The frequency of cost outliers varied from 7% to 8% across hospitals. Explanatory factors were: major or extreme severity of illness, longer length of stay, and intensive care unit stay. Cost outliers account for 22–30% of hospital costs. One-third of length-of-stay outliers are not cost outliers, and nearly one-quarter of charges outliers are not cost outliers. The current funding system in Belgium does not penalise hospitals having a high percentage of outliers. The billing generated by these patients largely compensates for costs generated. Length of stay and charges are not a good approximation to select cost outliers.

Epidemiology of Injuries in Belgium: Contribution of Hospital Data for Surveillance

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.

Evaluation of the cost of atrial fibrillation during emergency hospitalization

Objectives. Investigating injuries in terms of occurrences and patient and hospital stay characteristics. Methods. 17370 stays, with at least one E code, were investigated based on data from 13 Belgian hospitals. Pearsons chi-square and Kruskal-Wallis tests were used to assess the variations between distributions of the investigated factors according to the injurys types. Results. Major injuries were accidental falls, transport injuries, and self-inflicted injuries. There were more men in the transport injuries group and the accidental falls group was older. For the transport injuries, there were more arrivals with the support of a mobile intensive care unit and/or a paramedic intervention team and a general practitioner was more implicated for the accidental falls. In three-quarters of cases, it was a primary diagnostic related to injury and poisoning which was made. The median length of stay was nearly equal to one week and for accidental falls, this value is three times higher. The median cost, from the social security point of view, for all injuries was equal to €1377 and there was a higher median cost within the falls group. Conclusion. This study based on hospitals data provides important information both on factors associated with and on hospital costs generated by injuries.

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

Objective The number of hospitalizations for atrial fi brillation has increased dramatically. This increase, in the number of hospital stays will continue, given the growth projections based on epidemiological data, and will contribute to signifi cantly increase expenses for the social security system. The objective of this study was to evaluate the length of hospital stay, the average cost borne by social security, and the types of hospital stay expenditures for patients admitted through the emergency department for atrial fi brillation. Methods Patients were identifi ed by using the minimal clinical summaries of seven general hospitals in Belgium in 2008. Only hospitalized patients having as primary diagnosis code ICD-9-CM 42731 ‘atrial fi brillation’ were selected for this study. Hospital billing fi les were analysed in order to isolate the costs borne by social security. Outliers were isolated in order not to have results infl uenced by patients having an atypical length of stay. Results Results show that the mean length of stay was 8.6 days and the mean cost charged to social security was €3,066.02 per hospital stay. The mean cost of care was strongly associated with the degree of severity index related to the APR-DRG. Approximately 85% of the total cost was related to the cost of hospital days and medical procedures with medical imaging and laboratory tests being the two main cost inductors. 18% of patients had cardioversion during their hospital stay, including 4% who had only that treatment. 19% of patients used amiodarone. Flecainide and propafenone were also used, but less frequently. Conclusions The mean cost of care for AF patients admitted via the emergency department is strongly associated with the degree of severity. Approximately 85% of the total cost is related to the cost of hospital days and medical procedures. Hypertension is the most common secondary diagnosis. An optimal treatment of this risk factor could help to reduce the risk of atrial fi brillation, and thereby reduce the morbidity and costs associated with this disease.

Analyse médico-économique de la patientèle oncologique de 14 hôpitaux belges.

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

INTRODUCTION A prospective payment system per DRG is announced in Belgium. Is this kind of financing system adequate for oncology? Objectives of this study are: to analyze medical and economical characteristics of oncological inpatients and evaluate the homogeneity of costs and length of stay per DRG. METHODS The study was realized in 14 Belgian hospitals, with 2010 data. Inpatients with primary diagnosis of neoplasms were selected in medical and administrative databases. Characteristics of patients as well as length of stay and cost (hospital perspective) were analyzed. The homogeneity of costs and length of stay is measured by calculating the coefficient of variation (standard deviation divided by the mean). RESULTS The length of stay (standard deviation) is 9.72 days (12.64). The variation is high per DRG. The average cost (standard deviation) is 7689.28€ (10,418) and is also variable from one DRG to another one. There are 5% of high-length of stay outliers and 0.2% of low-length of stay outliers. There are 4.7% of high-cost outliers and 0.2% of low-cost outliers. The withdrawal of outliers improves the homogeneity of cost and length of stay per APR-DRG. DISCUSSION AND CONCLUSION There is a homogeneity of costs and length of stay per DRG and per severity of illness. A prospective payment system per DRG would probably be applicable for these patients. It is however necessary to plan an appropriate and additional financing of all elements susceptible to stimulate innovation in the management of oncology and to stimulate the quality of care by adding financial stimulants.