Miriam M. Wiley

Diagnosis Related Groups in Europe

Diagnosis-Related Group (DRG) systems were introduced in Europe to increase the transparency of services provided by hospitals and to incentivize greater efficiency in the use of resources invested in acute hospitals. In many countries, these systems were also designed to contribute to improving – or at least protecting – the quality of care. After more than a decade of experience with using DRGs in Europe, this book considers whether the extensive use of DRGs has contributed towards achieving these objectives.

The cost of stroke and transient ischaemic attack in Ireland: a prevalence-based estimate

BACKGROUND stroke is a leading cause of death and disability globally. The economic costs of stroke are high but not often fully quantified. This paper estimates the economic burden of stroke and transient ischaemic attack (TIA) in Ireland in 2007. METHODS a prevalence-based approach using a societal perspective is adopted. Both direct and indirect costs are estimated. RESULTS total stroke costs are estimated to have been €489-€805 million in 2007, comprising €345-€557 million in direct costs and €143-€248 million in indirect costs. Nursing home care and indirect costs together account for the largest proportion of total stroke costs (74-82%). The total cost of TIA was approximately €11.1 million in 2007, with acute hospital care accounting for 90% of the total. CONCLUSIONS the chronic phase of the disease accounts for the largest proportion of the total annual economic burden of stroke. This highlights the need to maximise functional outcomes to lessen the longer term economic and personal impacts of stroke.

Acute Hospital, Community, and Indirect Costs of Stroke Associated With Atrial Fibrillation Population-Based Study

Background and Purpose— No economic data from population-based studies exist on acute or late hospital, community, and indirect costs of stroke associated with atrial fibrillation (AF-stroke). Such data are essential for policy development, service planning, and cost-effectiveness analysis of new therapeutic agents. Methods— In a population-based prospective study of incident and recurrent stroke treated in hospital and community settings, we investigated direct (healthcare related) and indirect costs for a 2-year period. Survival, disability, poststroke residence, and healthcare use were determined at 90 days, 1 year, and 2 years. Acute hospital cost was determined using a case-mix approach, and other costs using a bottom-up approach (2007 prices). Results— In 568 patients ascertained in 1 year (2006), the total estimated 2-year cost was

From Prevention to Nursing Home Care: A Comprehensive National Audit of Stroke Care.

33.84 million. In the overall sample, AF-stroke accounted for 31% (177) of patients, but a higher proportion of costs (40.5% of total and 45% of nursing home costs). On a per-patient basis compared with non–AF-stroke, AF-stroke was associated with higher total (P<0.001) and acute hospital costs (P<0.001), and greater nursing home (P=0.001) and general practitioner (P<0.001) costs among 90-day survivors. After stratification by stroke severity in survivors, AF was associated with 2-fold increase in costs in patients with mild-moderate (National Institutes of Health Stroke Scale, 0–15) stroke (P<0.001) but not in severe stroke (National Institutes of Health Stroke Scale ≥16; P=0.7). Conclusions— In our population study, AF-stroke was associated with substantially higher total, acute hospital, nursing home, and general practitioner costs per patient. Targeted programs to identify AF and prevent AF-stroke may have significant economic benefits, in addition to health benefits.

The future cost of stroke in Ireland: an analysis of the potential impact of demographic change and implementation of evidence-based therapies

Background: Many countries are developing national audits of stroke care. However, these typically focus on stroke care from acute event to hospital discharge rather than the full spectrum from prevention to long-term care. We report on a comprehensive national audit of stroke care in the community and hospitals in the Republic of Ireland. The findings provide insights into the wider needs of people with stroke and their families, a basis for developing stroke-appropriate health strategies, and a global model for the evaluation of stroke services. Methods: Six national surveys were completed: general practitioners (prevention and primary care), hospital organisational and clinical audit of 2,570 consecutive stroke admissions (acute and hospital care), allied health professionals and public health nurses (discharge to community care), nursing homes (needs of patients discharged to long-term care), and patient and carers (post-hospital phase of rehabilitation and ongoing care). Results: The audit identified substantial deficits in a number of areas including primary prevention, emergency assessment/investigation and treatment in hospital, discharge planning, rehabilitation and ongoing secondary prevention, and communication with patients and families. There was a lack of coordination and communication between the acute and community services, with a dearth of therapy services in both home and nursing home settings. Conclusion: This multi-faceted national stroke audit facilitated multiple perspectives on the continuum of stroke prevention and care. An overall synthesis of surveys supports the development of a multidisciplinary perspective in planning the development of comprehensive stroke services at the national level, and may assist in regional and global development of stroke strategies.

DRGs as a basis for prospective payment.

BACKGROUND AND PURPOSE this paper examines the impact of demographic change from 2007 to 2021 on the total cost of stroke in Ireland and analyses potential impacts of expanded access to stroke unit care and thrombolytic therapy on stroke outcomes and costs. METHODS total costs of stroke are estimated for the projected number of stroke cases in 2021 in Ireland. Analysis also estimates the potential number of deaths or institutionalised cases averted among incident stroke cases in Ireland in 2007 at different rates of access to stroke unit care and thrombolytic therapy. Drawing on these results, total stroke costs in Ireland in 2007 are recalculated on the basis of the revised numbers of incident stroke patients estimated to survive stroke, and of the numbers estimated to reside at home rather than in a nursing home in the context of expanded access to stroke units or thrombolytic therapy. RESULTS future costs of stroke in Ireland are estimated to increase by 52-57% between 2007 and 2021 on the basis of demographic change. The projected increase in aggregate stroke costs for all incident cases in 1 year in Ireland due to the delivery of stroke unit care and thrombolytic therapy can be offset to some extent by reductions in nursing home and other post-acute costs.

Who's that sleeping in my bed? Potential and actual utilization of public and private in-patient beds in Irish acute public hospitals

Hospital care in Europe has for a number of years been changing towards prospective payment systems. The mechanisms of implementing PPS varies between countries and between health care systems. In the United States prospective payment for hospital care under Medicare was jointly introduced with DRGs being the basis for payment. The combined power of both techniques seems to surpass significantly the individual power of independent applications of PPS and DRGs. The DRG classification system is now the subject of experimentation and research in approximately 16 European countries. The prospects for case-mix measurement and prospective payment in Ireland are discussed in more detail.

Diagnosis Related Groups (DRGs): Measuring Hospital Case Mix†

Objective: To examine the impact of the unusual public/private mix on public and private in-patient bed utilization within Irish acute public hospitals. Methods: Data from the Department of Health and Children and the Hospital In-Patient Enquiry were used to estimate and compare potential and actual utilization of public and private designated in-patient beds in 54 acute public hospitals from 2000 to 2004. Results: Private in-patients used more bed days than were potentially available to them in 14.1% of hospital-year observations. The equivalent figure for public in-patients was 12.6%. Although the prevalence of excess utilization of private beds was relatively small, it did increase over the study period. Hospitals with excess private utilization were characterized by a relatively low proportion of private- or non-designated beds despite their patient profile being broadly similar to that of hospitals where there was no excess private utilization. Conclusions: Despite policies designed to limit private practice in Irish acute public hospitals, some hospitals have apparently been able to overcome these restrictions. In a system where financial incentives to treat private patients exist both for consultants and hospitals, it is not clear whether this excess private practice in public hospitals reflects a more efficient utilization of resources (when demand from public patients is low) or the displacement of public patients in favour of private patients. However, that a smaller number on hospital waiting lists possess private health insurance provides some support for the displacement hypothesis. Thus, it appears that policy-makers may need to reconsider attempts to ensure an appropriate division of acute public hospital resources between public and private patients.

Projecting the Impact of Demographic Change on the Demand for and Delivery of Healthcare in Ireland

The Diagnosis Related Group (DRG) system constitutes an approach to measuring hospital case mix that entails the separation of hospitalized patients into unique groups based on their diagnoses and procedures. Since originally developed in the United States in the 1980s, a number of versions of DRGs have developed to reflect the evolution in potential applications, in addition to developments in expertise, information technology, and data systems. Major initiatives in the development of DRG-type systems have taken place in Australia with the production of AR-DRGs and in a number of European countries. In addition to being applied extensively throughout North America, DRG-based applications are now widespread internationally, particularly in Europe and Australia. Keywords: case mix; major diagnostic category; diagnosis-related groups; Australian refined DRGs; HRGs ; prospective payment system