DRG 183 AND 184: ANALYSIS ON THE APPROPRIATNESS OF HOSPITAL ADMISSIONS ACCORDING TO PROTOCOL PRUO. A LOCAL EXPERIENCE

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1 CASEMIX Quarterly, Volume 1 Number 4, 31st December 1999 DRG 183 AND 184: ANALYSIS ON THE APPROPRIATNESS OF HOSPITAL ADMISSIONS ACCORDING TO PROTOCOL PRUO. A LOCAL EXPERIENCE Cinthia Manganaro, Erika Sampognaro, Maristella Bertoldo, Paolo Piergentili Ulss n. 13, Mirano (Ve) Communications to: Cinthia Manganaro, Ulss n. 13, via Mariutto 74, Mirano (Ve), Ph ; Fax 041, ; ulss13mirano.direzsanitaria@shineline.it ABSTRACT This paper evaluates, using the PRUO methodology, a random sample of hospitalisations in the three hospitals of Ulss 13 falling in DRG 183 and DRG 184. The most frequent criterion of appropriateness found was "Intra venous therapy two or more times per day", the second was "Nursing surveillance or intervention 4 or more times per day", and the third "Medical observation 3 or more times per day". The most frequent reason of inappropriateness has turned out to be the execution of diagnostic examinations. This finding are consistent with the hypothesis that in the two considered DRG are classified patients with low severity pathologies. The length of staying was found to be somewhat elevated (7.3 days of average). KEYWORDS: PRUO, DRG s, appropriateness INTRODUCTION The recent Health Reform in Italy (June 99) excludes from health services and procedures granted to all Italian citizens those which do not satisfy the principle of the effectiveness and the appropriateness, that is whose effectiveness is not demonstrated on the ground of the scientific evidences available or is used for subjects whose clinical conditions do not correspond to the recommended indications (art. 7 point b). The General Director of U.L.S.S. n 13 has the implemented a project which, through clinical guidelines, aims to establish an uniformity of clinical behaviours based on scientific evidences and inspired to the concepts of effectiveness and efficiency. A guidelines concerning dyspepsia was discussed in a joint workgroup by physicians from U.L.S.S. hospitals and General Practitioners with the collaboration of external advisers. Dyspepsia was selected as first item due to: the finding that, in year 1998, patients dismissed from hospital classified as DRG 183 (Esophagitis, gastroenteritis and other digestive symptoms without

2 CC, age > 17) and 184 (Esophagitis, gastroenteritis and other digestive symptoms without CC, age <= 17) were among the most frequent the high level of drug expenditure related to dyspeptic pathology; the high level of expenditure for diagnostic procedures related to dyspeptic pathology. As first phase of this project the appropriateness of the admission of a random sample of hospitalisations of persons resident in U.L.S.S. 13 classified in DRG 183 or 184 when dismissed. MATERIALS AND METHODS In the three hospitals of Ulss 13 in 1998, patients residents were dismissed. Of these, 514 were classified in DRG 183 and 262 in DRG 184, for a total of 776, that is, the 3,17% of the total. From these, a random sample of 250 dismissals has been extracted, 175 in DRG 183 and 75 in DRG 184; 66 of the latter have been eliminated since they were dismissal from a Paediatric units, where the P.R.U.O. methodology has not shown to be effective. Moreover, 6 clinical records of patients dismissed in DRG 183 and 2 in DRG 184 where not found. Thus, 169 and 7 clinical record pertaining respective to DRG 183 and 184 where examined according to P.R.U.O. methodology, an Italian methods derived from international standards 1-2. RESULTS The age distribution patients ranges from 11 to 97 years (mean 55.5, median 56.0); 103 were females and 73 males (apparently not meaningful difference); the mean age was 54.4 years for females and 57,1 for males. Ninety-two patients were dismissed from surgical units, 70 from medical units and 7 from maternal care unit (DRG 183), while 6 and 1 respectively was from surgical and medical area for DRG 184; The distribution of the length of staying goes from a minimum of 1 day to a maximum of 31, with average of 7.3 days and one median of 6.5; in table 1 detail for single hospital unit is shown. Table 1. LOS for hospital and hospital unit Unit N. Mean St. Dev. Surgery Dolo Geriatrics Dolo Internal Medicine Dolo Obstetrics Dolo ORL Dolo Surgery Mirano Internal Medicine Mirano Obstetrics Mirano

3 Surgery Noale Geriatrics Noale Long term care Noale Total The overall appropriateness distribution is shown in table 2. In table 3 the distribution for single hospital unit is reported. Table 2. Admission appropriateness and inappropriateness DRG tot tot. appropriateness tot. inappropriateness total The distribution of the appropriateness criteria is shown in table 4. All criteria have been considered (some dismissals were evaluated with more than a criterion), and therefore the total increases from 176 to 280; the distribution of inappropriateness reasons is shown in table 5; in this table too all reasons have been considered, for a total of 39 cases. In table 6 the distribution of criterion 16, when it is the only appropriateness criterion found, is reported. Note that when intravenous fluid therapy was the only criterion, but no drug was given, the criterion 20 (override negative) has been applied and this has been taken place in 13 cases (equal to the 15.9%); Table 3. Admission appropriateness and inappropriateness per hospital unit Unit appr. % app. inapp. Tot. Surgery Dolo Geriatrics Dolo Internal Medicine Dolo Obstetrics Dolo ORL Dolo Surgery Mirano Internal Medicine Mirano Obstetrics Mirano

4 Surgery Noale Geriatrics Noale Long term care Noale Total Table 4. Distribution of appropriateness criteria N. Criteria Cases % 16 Intra venous therapy 2 o more times per day Nursing observation/procedures 3 o more times per day Medical observation 3 o more times per day Negative override OR procedures Positive override Bleeding in the last 48 hours Systolic blood pressure < 90 or > 200, diastolic < 60 or > 120 mmhg Body temperature > 38 C from 5 or more days Acute neurological problems Therapy or side effects control Hydro-electrolytic, ph and metabolic problems Total Table 5. Distribution of inappropriateness reasons N. Reasons Cases % 31 Diagnostic procedures Medical therapy Surgical procedure Critical situation Total When criterion 16 is not the only one, the ulterior more frequent criteria are the 13 and 12 (respective 26 cases % and 25 cases %). Cases in which the presence of the n. 16 was the only criterion of appropriateness in admission, have given place to 285 days of hospital staying. The average was 7,1 days, minimum 1 day, maximum 21 days, st. dev.. 4.3, median 6 days. In the 13 cases in which, beyond to criterion 16, the negative override was applied, the mean LOS was 4,8 days and the standard deviation 2,5.

5 Table 6. Distribution of criterion 16 as stand alone criterion Unit Cases % Surgery Dolo Geriatrics Dolo Internal Medicine Dolo Obstetrics Dolo 0 0 ORL Dolo 0 0 Surgery Mirano Internal Medicine Mirano Obstetrics Mirano Surgery Noale Geriatrics Noale Long term care Noale Total The inappropriateness reason 31 as has been found 20 times in the Internal Medicine Units and 10 times in the Surgical Units. In table 7 the distribution of inappropriateness reason 31 by Hospital Unit is reported. Table 7. Distribution of inappropriateness reason n. 31 Unit Cases % Surgery Dolo Geriatrics Dolo Internal Medicine Dolo Obstetrics Dolo ORL Dolo Surgery Mirano 0 0 Internal Medicine Mirano Obstetrics Mirano Surgery Noale 0 0 Geriatrics Noale Long term care Noale Total

6 DISCUSSION Efforts towards a rational use of resources in health encourages the predisposition of instruments which eliminate ineffective medical practices and promote appropriate health care DRG 183 and 184 are very frequent in statistics of many hospitals 3-4 and are considered among those which easily include inappropriate hospitalisations 5. In the our sample the most frequently found criteria are the n. 16, the n. 13 and the n. 12 which, taken singularly, are thought to be weak criteria, and this confirms of the low severity of pathologies afferent to the considered DRG. The most frequent reason of inappropriateness was the n. 31. This is probably due to long waiting list for lab and other outpatient clinics, and to the cost, which can be relevant for outpatients, while there is no cost for inpatient 6,7. The mean LOS in our sample was 7,3 days and it appears to be rather high. In fact the largest number of hospitalisations has been classified with criterion 16, that is a weak criterion, which is found in cases with low severe pathology. The larger LOS observed in the Geriatrics Units probably reflects the advanced age of the patients. The other Hospital Units have similar mean LOS (around 7 days), except those where such hospitalisations are sporadic (Obstetrics and ORL). The mean LOS of the Internal Medicine Unit of Mirano Hospital is worth to be further studied, since the non parametric distribution of cases (not reported in this study), shows that a few cases with long hospital staying increase a great deal the mean. BIBLIOGRAPHY 1. G. Fellin e AA, Manuale Protocollo per la Revisione dell Uso dell Ospedale, Regione Veneto, Venezia Gertman PM, Restuccia JD. The appropriateness protocol: a technique for assessing unnecessary days of hospital care. Med. Care 1981, 19: E. Materia et. Al. Analisi degli archivi informatici e controlli esterni per la verifica di qualità della scheda di dimissione ospedaliera nella Regione Lazio. DRG 1996,4: I DRG in Lombardia nel Regione Lombardia, Milano Gruppo di lavoro PRUO. La valutazione dell uso dell ospedale: quadro di riferimento, strumenti di misurazione ed esperienze italiane.ricerca & Pratica 1994, 58: Galanti F., Franzo A. Nejad Amiri AG, et al. Il PRUO è un metodo di studio dell efficienza ospedaliera? QA, 1997, 8: Lattuada e AA, La valutazione dell appropriatezza dei ricoveri nell esperienza del Friuli-Venezia Giulia. Tendenze Nuove 1998