DRG in Acute Care Services, Multi-trauma, Intensive Care ... · DRG in Acute Care Services, Multi-trauma, Intensive Care, Emergency Unit Professor Hans Flaatten, MD PhD ... •Bjørn

DRG in Acute Care Services, Multi-trauma, Intensive Care,

Emergency Unit Professor Hans Flaatten, MD PhD

University of Bergen, Haukeland University Hospital

Bergen Norway

DRG in Critical illness Professor Hans Flaatten, MD PhD

University of Bergen, Haukeland University Hospital

Bergen Norway

Overview of my presentation

• Short history of Critical Care in Europe /Nordic countries

• Various critical care services and their relations

• What is Critical Care Medicine/Intensive Care Medicine

• Nordic intensive care medicine-present status

• Cost of Intensive Care

• Intensive care medicine = Acute vital organ failure

• How can we ”measure” organ failure

• The epidemiology of organ failure in intensive care

• Methods to fund Intensive Care

• Analysis of our own Unit 2015 with regard to DRG

• Todays refunding practice

• Suggestions from a clinician

The polio epidemic 1952-53

• During the large polio epidemic in Copenhagen 1952-53 a very high mortality in patients with bulbo-spinal paresis was noted

• The speciality of Infectious Diseases had little but comfort to give

• In spite of considerable opposition and scepticism the anestesiologist Bjørn Ibsen was allowed to demonstrate his “solution” and contribution to this massive problem

• The “anaesthesia” solution

Bjørn Ibsens publication

Ibsens theory

• Ibsen firmly believed that the treating physicians did not recognize the considerable hypo-ventilation in these patients

• In lay terms, their breathing was insufficient to eliminate carbon-dioxide, and eventually also for oxygen uptake

• The record of his first patient have been found, and demonstrate a minute to minute medical record for the first two days after start of treatment

Further progress

• Continued to receive hand-ventilation 24/7 until Jan 1953

• Fed through a gastric tube • In 1955 the technology had

advanced sufficiently to allow her having a positive pressure ventilator

• Remained in hospital until 1959! Still ventilator dependent

• Died June 1971 from pneumococcal sepsis.

• Bjørn Ibsen died in 2007

Relations (volume)

EMERGENCY CARE WARDS &

HDU

HOME

ICU

✞

Relations (use of resources)

EMERGEN-CY CARE

WARDS & HDU

H

ICU ✞

Why is the use of resources so high in ICU?

1. The intensity in the treatment of Organ failure: • Medical technical equipment

• Ventilators • Circulatory assist devices • Renal Replacement Therapy

• Medications and disposals

2. The high nurse : patient ratio • In Scandinavia 1:1 24/7

3. The constant presence of physician(s) in the ICU 24/7

Nordic ICU data 2010

Denmark North Denmark Sweden 1 Finland 2 Norway 3

ICU admissions 28.172 (3y) 33.361

41.500 16.789 14.135

Admissions/105 521 603

461 329 288

Medical 39,4% NA 71,1% 64,5% 52,5%

Surgical 60,6% NA 11,6% 19,0% 29,8%

Planned surgical NA NA 17,3% 16,5% 17,7%

1= data from SIR; 2= data from Intensium; 3 data= from NIR

Denmark > Norway and Finland combined in 2010

Depends from how we include patients

ICU database n=1

Administrative database n=2

The average costs of an ICU day and stay (1999) per patient were €2601 and €14,223, respectively, and the average cost per year of survival per patient was € 684. Average price per ICU day was €2601 (1999) ≈ € 3636 (2016) Or ≈ 34.000 NKr

Expenses: ICU HUS 1997-1999

50%

11%

8%

7%

6%

6%

3% 3% 1% 5%

Expences Nurse salary

Physician salary

Drugs

Blood products

Other consumptions

MTU

Lab

Overheads

Physiotherapy

X-ray/OP (est)

Cost of care: survivors

• 640 survivors (≈60%) • further expected to live 24.428 years • Average cost/life year: 684 €

INTENSIVE CARE =

MANAGEMENT OF PATIENTS WITH ACUTE ORGAN FAILURE

1.Respiratory 2.Circulatory 3.CNS 4.Renal 5.Gastrointestinal (Liver) 6.Coagulation/bleeding

Organ failures are interrelated

MULTI ORGAN FAILURE = MOF

Organ failure kills!

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ICU survivors ICU deaths ICU LOS Admissions x 10

Organ failure score

Survival % Admission ICS days

Can we describe OF in a simple way?

The SOFA score

JAMA 2016; 315 (8) 801-10

For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%.

Sequential Organ Failure Assessment score

SCORE Ventilation Oxygen/ratio + Ventilation

Circulation Mean ABP + vasopressor

Renal Creatinine + Urine output

CNS GCS

Hepatic Bilirubin

Coagulation Platelets

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Score can vary from 0 to 24 in one day

Sequential Organ Failure Assessment score

SCORE Ventilation Oxygen/ratio + Ventilation

Circulation Mean ABP + vasopressor

Renal Creatinine + Urine output

CNS GCS

Hepatic Bilirubin

Coagulation Platelets

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3 and 4 = severe organ failure

The prevalence of severe OF in 2528 patients HUS 2009-2014

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Respiratory Circulatory Renal CNS

Number %

Conceptual framework: Resource use in the ICU

Time

Resources

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Conceptual framework: Resource use in the ICU

Days

SOFA

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Sum of individual SOFAdays= TOTALsofa

Severity of disease

LOS

A simple group analysis of “burden of disease”

Four “groups” of ICU patients

1. Low LOS & Low severity 2. High LOS & High severity 3. High LOS & Low severity 4. Low LOS & High severity

Severity of disease

LOS

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Quick in/out

Quick in/dies Long-stayer: Seriously ill

Long-stayer: Single organ

Four “groups” of ICU patients 2009-2015

1115

1298

379

164

1. Low LOS & Low tSOFA 2. High LOS & High tSOFA 3. High LOS & Low tSOFA 4. Low LOS & High tSOFA

SOFAsum

LOS (days)

Median 2,87

median 17

Four “groups” of ICU patients 2009-2015 SOFAsum

LOS (days)

2,87

17

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admissioins

ICU LOS

Ventilator days

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458 164 342 206

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Admissions LOS Ventilator days

Use of resources

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Clinical use of the SOFA score

• To describe the “burden” of organ dysfunction in a specific ICU or in groups of ICUs

• To document the incidence of severe organ failure in the six vital organ systems (SOFA score 3 or 4)

• Prognostic value (series of daily SOFA score)

• Is there a potential for its use in reimbursement?

Analysis of patients in our general ICU 2015

• HUS has one general ICU, only what is considered ICU patients are admitted

• March 2015:

• All DRGs were retrieved from the hospital administrative system.

• These data were compared with our ICU management database (ICIP) regarding • Organ failure (Total SOFA score) • LOS • Length on ventilator • Common ICU codes/procedures • Outcomes

• We have three other adult units who also accept ICU patients

• They are all mixed units: • Postoperative patients-some ICU patients

(Cardiothoracic Postop/ICU) • Cardiac observation unit/Medical ICU

patients • Burn unit: 4 ICU beds/4 general beds

• The mixed units are common in Norway, and make comparisons difficult. Mixed units tends to overestimate the number of ICU admissions, that is why number of admission as a poor outcome parameter (in any sense

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SOFAtotal & Time on ventilator

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SOFAtotal & NEMS

A hypothetical model to consider

DRG groupSOFA DRG range Admissions SOFAtotal Weight Sum SOFA/points

1 < 10 122 620 0,15 18,3 33,88

2 10-20 109 1481 0.4 43,6 33,97

3 20-50 111 3667 1 111 33,04

4 50-100 54 3646 2 108 33,76

5 100-200 32 4304 4 128 33,63

6 ≥ 200 7 2239 10 70 31,99

STRENGTH WEAKNESSES Can be used to describe all types of ICU patients – from low to high resource use Avoid the problem of defining organ failure/dysfunction Would be considered a very fair system from a clinical point of view

Requires that ICUs must calculate SOFA scores daily on all admitted patients Children at present not included in SOFA score May not truly reflect the cost of highly specific ICU procedures like ECMO and LV assist devices Readmission must be calculated differently

OPPORTUNITIES THREATS May act as an “carrot” for ICU to start using the SOFA score, a score that is advocated by NIR (but not yet compulsory) Can be adapted to several variations from fixed point/SOFA point, to creating of different classes, or exclude SOFA scores below a threshold.

ICU community refuses to use SOFA score because of time consumption Although very objective, all systems can be manipulated. In SOFA particularly the CNS part with GCS scoring

What is todays practice Norway and elsewhere

Vincent, Takala, Flaatten: Am J Respir Crit Care Med Vol 185, Iss. 2, pp 119–123, Jan 15, 2012

Different reimbursement methods

• Revenue based system • Not very common in Europe, mostly USA

• Yearly budget system • Usual in several EU countries. Often in combination with DRG

• DRG based system • Gained popularity in Europe • Used in Germany since 2003 • Drawbacks:

• … and the often missing direct link between underlying diagnosis and need for ICU resources

• DRG systems must therefore include elements that enable unpredictable and complex ICU treatments to be covered; otherwise, the risk of under- funding of the ICU is substantial.

Codes for diseases relevant for ICU patients

• Usually does not reveal severity of the disease • Seasonal influenza A (J10) good

example • Diagnosis depends on traditional

signs and symptoms + detection of the virus

Codes for procedures relevant for ICU patients • Some codes reflects resource use in a direct way

• FXE 00 ECLA Extracorporeal membrane oxygenation (ECMO)

• Some codes reflects resource use in an indirect way • GBB 00 Tracheostomy

• Many codes does not reflects resource use at all • WLGP29 Hyperbaric oxygen therapy INA

• WLGX50 Isolation

• KAGD46 Hemofiltrasjon

• GXAV20 BiPAP (bipahsic positive pressure ventilation)

1A-E 148 475

A 483

HUS General ICU 2015

DRG weight 2015: Our ICU patients

• Number of patients 459

• Number of admissions 506

• ICU LOS 2.760

• Hospital LOS 11.907

• Sum DRG points 4.860 • From DRG 483 alone: 3.305 (68% of all DRG points)

• Sum 2015 NKr 201.500.000

• ICU costs adjusted* 93.840.000 (≈ 47% of DRG reimbursement)

* From results 1997-1999

The 4 most frequent DRG groups: 2015

DRG groups Admissions =397*

Total SOFA =16.212

SUM DRG w = 4.572

% total DRG w DRG per SOFA point

1 A-E 31 572 (3.5%) 246 5,4 0,4304

148 21 348 (2.1%) 83 1,8 0,2385

475A 33 810 (5.0%) 100 17,8 0,1229

483 98 8878 (54.8%) 3177 69,7 0,3578

All other groups 214 5604 (34.7%) 951 20,8 0,1698

*Calculated just on all first admissions 2015 with a relevant SOFA score

Neonatal Intensive Care - DRG

• Within this specific ICU group there are several DRG groups according to the severity of their condition, measured as birth weight (bw)

• BW is in many ways an indirect measure of time: the lower weigth, the longer time in treatment

• DRG (Norwegian version/codes)

• 386N (bw< 1000g) • 24.727

• 387N (bw 1000-1499g) • 16.197

• 388A (bw 1500-2499 + other) • 8.590

• 388B (bw 1500-2499 – other) • 3,346

Intensive care DRG in Denmark

Ugeskrift læger 2007; 169: 8

• ICU group 1: Simple OF in 1-2 organs • ICU group 2: Increasing severe OF in one organ • ICU group 3: Increasing severe OF in several organs • ICU group 4: Severe multi OF

Good intentions, but no clear definition of OF, and increasing & severe

Denmark (cont)

2612 2612 Intensiv gruppe IV: Alvorligt multiorgansvigt 608 039 609 370 77

2613 2613 Intensiv gruppe III: Tiltagende alvorligt organsvigt i flere organer 478 960 480 008 65

2614 2614 Intensiv gruppe II: Tiltagende alvorligt organgsvigt i et organ 283 333 283 953 48

2615 2615 Intensiv gruppe I: Simpelt organsvigt i et eller to organer 275 482 276 086 51

Only patients in the ICU > 72 hours will be reimbursed after this system if they have a relevant diagnosis or procedure code. The rest (< 72 h) is reimbursed using the traditional DRG system

1115

1298

379

164

SOFAsum

LOS (days)

Median 2,87

median 17

Discussed in Norway 2006

• To use SOFA score (SOFAtotal), three groups: • Severe OF in one organ: SOFAtotal < 35 • Severe OF in 2 organs: SOFAtotal 35-100 • Severe OF in 3+ organs: SOFAtotal >100

• Use of relevant therapeutic codes for Intensive Care (NCSMP)

• These suggestions were not implemented. Two main issues: • Severe OF was not defined • There are patients not fitting into the model, ex one severe OF with SOFA > 35

• 5.1.3 Intensive care

• Defined as the time the patient is in intensive care. Data can be supplied with information about NEMS score and other systems that gives information about intensity of care.

• 6.6.3 Intensive Care

• Main driver of cost: Time in the ICU (ICU-LOS)

From IS: report 2033 Cost per patient (KPP)

The problem of LOS-ICU

• Probably not a good indicator of anything. • Above a certain threshold

probably an indicator of poor performance

• It can also be an indicator of difficult discharge to wards

• Seemingly similar hospitals differs a lot in their mean LOS in the ICU

• This is not connected to survival or severity of illness issues

My suggestions

• To use SOFA score to define organ failure in our ICUs

• To use SOFAtotal to measure the burden of disease.

• To create different DRG intensive care groups based on SOFAtotal , and use this for reimbursement purposes forpatients treated in the ICU

• Diagnostic and therapeutic codes still important to describe disease profiles and details in ICU treatment. Some codes could be used to “fine-tune” the system

• To test this in a larger samples of ICU patients across the Nordic area

Organ failure kills

798 845 712

271 373

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115 123

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SeverE Organ Failure – ICU outcome: HUS 2009-2015

Alive Dead

Number of organs in severe failure (SOFA 3 or 4)

Tidsskr Nor Lægeforen nr. 7, 2005; 125: 903–6

ICU admissions per year / 105

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Denmark

Sweden

Finland

Norway

Admissions/100.000 • We have a problem: 1. Either the populations in

Sweden and Denmark are sicker than in Norway and Finland

2. OR, the concepts of what defines an ICU patient are different

Organ dysfunction over time (2009-2014)

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Chart Title

Vekt Sum Total SOFA

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THE SIX VITAL ORGAN FUNCTIONS