Introduction to the EuroDRG project: main research objectives

Transcription

1 Introduction to the EuroDRG project: main research objectives Reinhard Busse, Prof. Dr. med. MPH FFPH Department of Health Care Management, Berlin University of Technology & European Observatory on Health Systems and Policies on behalf of the EuroDRG team 1

2 HowI gotinterestedin DRGs (2002) A policy question in the 6th EU Framework Programme: Why do costs of health services differ among EU countries at the micro level? The first nine patients sent to France by the English NHS (not shown: the 40 journalists who accompanied them) 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Cataract Hip Knee Are these data realistic? Are they representative? How can the differences be explained? NHS UK private France 2

3 Using 10 vignettes across countries (with standardised description of patients) 10000,00 in 9000,00 E.g. Acute myocardial infarction 9374, , , , , , , , , , , ,00 0,00 Hungary (N=2) 395,97 483,05 308,88 Poland 1415, ,76 592,15 Spain 2541, , ,55 Denmark 2733, , ,40 Germany (N=13) 4161, , ,53 England 5013, ,16 France 6225, , ,53 Netherlands (N=6) 5599, ,88 Italy 4384,72 Published in Health Economics 2008; 17(S1) 3

4 10000,00 in 9000, , , , , , , , ,00 0,00 patient variables gender, age, main diagnosis, other diagnoses, severity Hungary (N=2) 395,97 483,05 308,88 Poland 1415, ,76 592,15 Acute myocardial infarction medical and management decision variables mix and intensity of procedures, technologies and human resource use Spain 2541, , ,55 Denmark 2733, , ,40 Germany (N=13) 4161, , ,53 England 8282, , , , , , , , ,88 structural variables on hospital/ regional/ national level e.g. size, teaching status; urbanity; wage level France Netherlands (N=6) Italy 9374, , ,72 4

5 10000,00 in 9000, , , , , , , , ,00 0,00 patient variables gender, age, main diagnosis, other diagnoses, severity Acute myocardial infarction medical and management 8282, ,89 Open question decision variables 1: How much do 6225, , , ,53 mix and intensity of procedures, 5013, ,15 these variables contribute to cost Hungary (N=2) take them into 2866,36 account)? 2733, , , , , , , , , ,53 592,15 395,97 483,05 308,88 Poland technologies and human resource use variation (and do DRG systems Spain Denmark Germany (N=13) England France Netherlands (N=6) 3720,88 structural variables on hospital/ regional/ national level e.g. size, teaching status; urbanity; wage level Italy 9374, , ,72 5

6 10000,00 in 9000, , ,00 Acute myocardial infarction: Hospitals performing PCI (PTCA/ Stenting) none mixed all 8282, , , , , , , , , ,00 0,00 Hungary (N=2) > factor 4: value for money? 395,97 483,05 308,88 Poland 1415, ,76 592,15 Spain 2541, , ,55 Denmark 2733, , ,40 Germany (N=13) 4161, , ,53 England 5013, ,16 France 6225, , ,53 Netherlands (N=6) 5599, ,88 Italy 4384,72 6

7 10000,00 in 9000, , ,00 none Acute myocardial infarction: Hospitals performing PCI (PTCA/ Stenting) mixed 8282,36 all 7616,89 Open question 2: If costs differ 6225,55 so 6000, , , , , , , , , , ,00 0,00 much with treatment, what about Hungary (N=2) 395,97 483,05 308,88 Poland the quality of care? 1415, ,76 592,15 Spain 2541, , ,55 Denmark 2733, , ,40 Germany (N=13) 2866, ,53 England 2868,16 France Netherlands (N=6) 3720,88 Italy 9374, , ,72 7

8 Hip implant Reimbursemen nt (Euros) Denmark England France Hospitals in NL Germany Hungary Italy Netherlands Poland Spain Total cost (Euros) 8

9 Hip implant Reimbursemen nt (Euros) 8000 Open question 3: Do costs differ even 6000 more(and why) if we include Denmark 4000 different patient characteristica? Germany Total cost (Euros) England France Hungary Italy Netherlands Poland Spain 9

10 Suomi Finland Countries covered by EuroDRG project 10

11 Whatdidwedo? Phase I DRG system design and characteristics How do DRG system in Europe work? Why and when implemented? How does patient classification work? Where do data come from? Uniform or regionally adapted? How often updated? Impact on efficiency and quality? Phase II empirical performance evaluation Phase III conclusions Conclusions for policy-makers within and beyond European countries 11

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13 Whatdidwedo? Phase I DRG system design and characteristics Phase II empirical performance evaluation For 10 episodes of care cross-country comparisons of (1) actual classification, DRG catalogues, DRG patient-level (2) reimbursement, databases, reimbursement lists (3) factors explaining cost variation, (4) cost-quality relationship Phase III conclusions empirical evaluations with patient-level data bases including costs/ length-of-stay 13

14 The episode of care approach Why? Evaluation of hospital performance requires to look at a set of comparable/ adjustable patients we chose all patients with a certain diagnosis and/ or procedure Why not using DRGs directly? DRG classification differs across countries to study effects we needed to define meta-drgs Selection criteria for episodes of care Relatively frequent ( we wanted to work with original patient data) Representing different medical specialties (internal medicine, surgery, obstetrics and gynaecology etc.) Involving diagnostic and/or therapeutic procedures (including the use of innovative technologies) Coding within and across countries deep enough to allow for analysis of differences 14

15 Finland - THL England - CHE Austria - MSIG Netherlands - ibmg Poland - NHF Spain - IMAS Germany - TUB Sweden - CPK EoCand related questions Recommended forinclusion? (/no) Recommended forinclusion? (/no) Recommended forinclusion? (/no) Recommended forinclusion? (/no) Can you differentiate the following items? (/no) Remarks Recommended forinclusion? (/no) Recommended for inclusion? (/no) Recommended for inclusion? (/no) Recommended forinclusion? (/no) 1. Breast cancer Types of carcinoma (invasive and not invasive) no NO - CANNOT IDENTIFY DISEASE STAGE, SO COMPARABILITY PROBLEMATIC Stages of the disease (TNM, IUCC ), grade of the disease (G1-G4) Protein and geneexpression status (oestrogen receptor (ER), progesteronereceptor (PR) and HER2/neu proteins) Types of treatment: surgery, radiation, hormone immune and chemotherapy Types of surgery: tumourectomy, mastectomy - with or without lymph-adenectomy and reconstruction 2. Colorectal cancer Location of the cancer, i.e. in the colon (possibly further specified), no rectum and caecum Stages of the cancer (TNM, IUCC, Dukes classification ), grade of the disease (G1-G4) Types of treatment: surgery, radiation, chemotherapy Extent of surgery (both within colon/ rectum and other organs) 3. Diabetes mellitus Types of diabetes (type 1 and type 2) Reason for admission (e.g. hyperglycaemic or hypoglycaemic shock; other complications), Procedures related to the main diagnosis diabetes (e.g. amputation) 4. Acutemyocardialinfarction(AMI) Type of acute myocardial infarction (both ST-elevated MI [STEMI] and non-st-elevated MI [NSTEMI]) Treatment (PTCA, stent, CABG/bypass) 5. Percutaneous coronary interventions (PCI) Indications for PCI Treatment (PTCA, stent) Location of intervention (number of vessels treated, affected coronary artery, bifurcation ) Details of stent (bare metal vs. drug-eluting; number of stents, affected coronary artery, type of drug on DES ) 6. Coronary artery bypass graft surgery (CABG) Indications for CABG Grafting of both types of blood vessels: arteries and veins Type of surgery: with the usage of cardiopulmonary bypass or socalled off-pump surgery 7. Stroke Cause (due to ischemia (thrombosis or embolism) or haemorrhage) Treatment settings (ICU, stroke unit or medical/ neurological ward) Rehabilitation within operating hospital or associated settings (vs. rehabilitation after transfer, i.e. after end of episode) 8. Community-acquired pneumonia, although is complicated NO - CANNOT IDENTIFY DISEASE STAGE, SO COMPARABILITY PROBLEMATIC, however we should explicitly in- or exclude certain treatments., but a detailed definition is required We could have a clear picture of breast cancer. We could have a clear picture of colorectal cancer. However, we can not identify patients who had both surgery and chemotherapy. NO It is rather difficult to get a clear picture of diabetes mellitus, predominantly owing to the many departments involved and the inability to link them. YES We could have a clear picture of acute myocardial infarction, except when it comes to CABG procedures., requires exact definition of procedure codes in order to secure comparability between countries, requires exact definition of procedure codes in order to secure comparability between countries YES We could have a clear picture of PCI procedures. However, the number of diagnosis-codes may turn out to be too extensive/ complex to work with. YES We could have a clear picture of CABG procedures. However, we can not distinguish the underlying diagnoses (such as acute myocardial infarction). YES We could have a clear picture of stroke. Hospital-acquired pneumonia (nosocomial) (e.g. by special codeor no NO It is rather difficult to get a clear picture of present on admission code) community-acquired pneumonia, because we can not distinguish between hospital and community-acquired pneumonia. Treatment settings (ICU or medical ward) Type of treatment (especially antibiotics) 9. Inguinal hernia repair Type of inguinal hernia (bilateral unilateral, direct indirect) YES, should we define a minimal age? It is rather difficult to get a clear picture of inguinal hernia repair, because we can not distinguish between hernia femoralis and inguinalis. Type of surgical repair (with or without graft or prosthesis implant) Treatment setting (inpatient, outpatient) 10. Appendectomy Type of surgery (laparoscopic or open) YES We could have a clear picture of appendectomy. Treatment setting (inpatient, outpatient) 11. Cholecystectomy Type of surgery (laparoscopic or open) YES It is rather difficult to get a clear picture of cholecystectomy. However, we could have a clear picture of cholecystitis. Treatment setting (inpatient, outpatient) 12. Hip replacement Indication (osteoarthritis, other types of arthritis, protrusio acetabuli, avascular necrosis, hip fractures and benign and malignant bone tumours) Type of replacement (e.g. hemiprosthesis, total endoprosthesis, resurfacing) Type of surgery (cemented, cementless and hybrid prosthesis) First replacement vs. revision Rehabilitation within operating hospital or associated settings (vs. rehabilitation after transfer, i.e. after end of episode) YES We could have a clear picture of hip replacement. However, we can not always distinguish the underlying diagnoses. No No No No No No No No No ICD10 excluding hormoneimmune ICD9 ICD10 ICD9 ICD9 ICD9 ICD9 ICD9 ICD9 ICD10 inpatient only inpatient only inpatient only ICD10 YES YES YES YES NO or maybe we think about redefining parameters of the episode NO or maybe we think about redefining parameters of the episode YES YES YES YES YES, but cannot identify disease stage, but cannot identify disease stage, but some difficulties, but no information on type of antibiotics used for treatment but not possible to identify direct/indirect, but difficult to know numbers for rehabilitation Selected episodes of care: Appendectomy Cholecystectomy AMI Bypass (CABG) Stroke Inguinal hernia Hip replacement Knee replacement Breast cancer Childbirth Dropped: Colorectal cancer Diabetes Com.-acq. Pneumonia Urolithiasis Traumatic brain injury 15

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17 Patient-level data bases used(topics 3 & 4) 17

18 For further reading(topic 3) 18

19 For further reading(topic 3) 19

20 Austria England/ UK EuroDRG project partners Department for Medical Statistics, Informatics and Health Economics, Innsbruck Medical University Centre for Health Economics, University of York Estonia Europe Finland France Germany Ireland Netherlands Poland Portugal Spain Sweden PRAXIS Center for Policy Studies, Tallinn European Health Management Association, Brussels National Institute for Health and Welfare, Helsinki École des hautes études en santé publique, Rennes & Institut de recherche et documentation en économie de la santé, Paris Department of Health Care Management, Technische Universität Berlin Economic and Social Research Institute, Dublin Institute for Health Policy & Management, Erasmus Universitair Medisch Centrum Rotterdam National Health Fund, Warsaw Avisory board member Céu Mateus Institut Municipal d Assistència Sanitària, Barcelona Centre for Patient Classification, National Board of Health and Welfare, Stockholm 20

21 EuroDRG consortium members Picture: 22nd January 2010, Paris 21