Implictions of DRG Clssifiction in Bundled yment Inititive for COD TRISHA M. AREKH, DO; SURYA. BHATT, MD; ANDREW O. WESTFALL, MS; JAMES M. WELLS, MD; DENAY KIRKATRICK, DN, AN-BC; ANAND S. IYER, MD; MICHAEL MUGAVERO, MD; JAMES H. WILLIG, MD; AND MARK T. DRANSFIELD, MD ABSTRACT OBJECTIVES: Institutions prticipting in the Medicre Bundled yments for Cre Improvement (BCI) inititive invest significntly in efforts to reduce redmissions nd costs for ptients who re included in the progrm. Eligibility for the BCI inititive is determined by dignosis-relted group (DRG) clssifiction. The implictions of this methodology for chronic diseses re not known. We hypothesized tht ptients included in BCI inititive for chronic obstructive pulmonry disese (COD) would hve less severe illness nd decresed hospitl utiliztion compred with those excluded from the bundled pyment inititive. STUDY DESIGN: Retrospective observtionl study. METHODS: We sought to determine the clinicl chrcteristics nd outcomes of Medicre ptients dmitted to the University of Albm t Birminghm Hospitl with cute excerbtions of COD between 2012 nd 2014 who were included nd excluded in BCI inititive. tients were included in the nlysis if they were dischrged with COD DRG or with non-cod DRG but with n Interntionl Clssifiction of Diseses, Ninth Revision code for COD excerbtion. RESULTS: Six hundred nd ninety-eight unique ptients were dischrged for n cute excerbtion of COD; 239 (34.2%) were not clssified into COD DRG nd thus were excluded from the BCI inititive. These ptients were more likely to hve intensive cre unit (ICU) dmissions (63.2% vs 4.4%, respectively; <.001) nd require noninvsive (46.9% vs 6.5%; <.001) nd invsive mechnicl ventiltion (41.4% vs 0.7%; <.001) during their hospitliztion thn those in the inititive. They lso hd longer ICU length of sty (5.2 vs 1.8 dys; =.011), longer hospitl length of sty (10.3 dys vs 3.9 dys; <.001), higher in-hospitl mortlity (14.6% vs 0.7%; <.001), nd greter hospitliztion costs (medin = $13,677 [interqurtile rnge = $7489-$23,054] vs $4281 [$2718-$6537]; <.001). CONCLUSIONS: The use of DRGs to identify ptients with COD for inclusion in the BCI inititive led to the exclusion of more thn one-third of ptients with cute excerbtions who hd more severe illness nd worse outcomes nd who my benefit most from the dditionl interventions provided by the inititive. The Americn Journl of Accountble Cre. 2017;5(4):e1-e7 Rising costs hve led to number of federl inititives to reform the US helthcre pyment system nd reimburse providers nd hospitls bsed on outcomes rther thn volume. As prt of multipronged strtegy to control costs nd ddress qulity concerns, CMS hopes to tie more thn 50% of pyments to lterntive vlue-bsed models by the end of 2018. 1 One such progrm is the Bundled yments for Cre Improvement (BCI) inititive, which reimburses hospitls nd providers bsed on episodes of cre over time rther thn individul fee-for-service (FFS) billing. The BCI inititive includes 4 distinct models. In Model 2, reimbursements cover the cost of n index dmission, professionl fees, nd ll Medicre prt A nd B costs, including postcute cre nd ll-cuse redmissions within 30, 60, or 90 dys of n index hospitliztion dischrge. 2 Reimbursements for n episode of cre within this model re bsed on n inptient clssifiction system developed in the 1980s tht divides dignoses into ctegories, known s dignosis-relted groups (DRGs), to determine pyment. The DRG ssignment is given by the hospitl coders with the use of semi-utomted grouper computer coding system. Hospitl coders input specific informtion (eg, primry nd secondry Interntionl Clssifiction of Diseses, Ninth Edition [ICD-9] codes, complictions, procedures, sex, gender) into the grouper, which connects clinicl ttributes to resource utiliztion in order to ssign specific DRG. 3 At the University of Albm t Birminghm (UAB), our medicl coders use the grouper system Optum CAC ( computer ssisted coding ). The plnned reimbursement, or trget price, for given DRG in ech BCI inititive is bsed on historicl dt nd djusted for cse mix nd region. Hospitls my either owe Medicre for overges or gin shred svings with providers depending on whether totl BCI chrges exceed or fll below the trget price. 12 / 12.17 The Americn Journl of Accountble Cre
As prticipnt in Model 2 of the BCI inititive for ptients hospitlized with cute excerbtions (AEs) of chronic obstructive pulmonry disese (COD), our institution hs invested significnt finncil resources into the development of multidisciplinry progrm to deliver specilized interventions to ptients included in the BCI inititive, including expedited follow-up visits in CODfocused clinic, home clls, mediction ssistnce, nd tobcco cesstion counseling. 4 Knowledge of the chrcteristics nd outcomes of ptients who were ultimtely included nd excluded from the BCI cn guide the mturtion of progrms similr to ours. Our study sought to: 1) determine the clinicl chrcteristics of ptients dmitted with AEs of COD who were included nd excluded from the BCI (bsed on DRG coding) nd 2) evlute differences in outcomes, hospitl length of sty (LOS), nd cost utiliztion between these groups. Bsed on our experiences prticipting in the BCI, we hypothesized tht ptients excluded from the BCI inititive would hve higher rte of intensive cre unit (ICU) dmission nd use of mechnicl ventiltion, longer hospitl LOS, nd incresed index dmission costs thn those who were included in the inititive. METHODS Estblishment of the Study Cohort We included Medicre beneficiries who were dmitted to UAB Hospitl between Jnury 1, 2012, nd December 31, 2014, for n AE of COD s defined by dministrtive dt. 2 As the BCI inititive currently stnds, only Medicre FFS ptients re included. However, we included ll Medicre ptients (FFS, mnged Medicre, dul-eligible) in our nlysis to increse the power of the study nd becuse pyment to privte insurers my model the bundled pyment pproch in the future. tients were included if they received COD DRG (190-192) upon dischrge or n ICD-9 code tht hd trditionlly been used to identify n AE of COD (primry code 491.21 or 491.22; or primry code 518.81, 518.82, 518.84 with 491.21, 491.22, or 496 s secondry). 5,6 In order to focus on COD-specific DRGs, we excluded sthm DRGs (202-203) nd therefore did not include ICD-9 codes relted to sthm, nonspecific lung disese, or unspecified bronchitis. 7 We identified 990 ptient encounters with dischrge dignosis of AE of COD bsed on COD DRG ssignment or ICD-9 coding. Of these, 698 unique ptients in 2 mutully exclusive groups were included for nlysis: 1) those dischrged with COD DRG (DRG group) nd 2) those dischrged with COD ICD-9 code nd non-cod DRG (ICD-9 group). UAB s Institutionl Review Bord pproved the study protocol (X121221005). Dt Dt were extrcted from our hospitl s clinicl dt wrehouse (Cerner owerinsight; Cerner Corportion World Hedqurters; North Knss City, Missouri). Demogrphic informtion nd comorbidities were obtined from the time of index hospitliztion. Encounter informtion obtined included clinicl dt from hospitliztion (vitl signs, rteril blood gs vlues, body mss index [BMI], smoking sttus, use of noninvsive positive pressure ventiltion [NIV], invsive mechnicl ventiltion) nd dministrtive dt (hospitl nd ICU LOS, hospitl disposition). All-cuse redmissions were evluted t 30 nd 90 dys from index hospitl dischrge; the ltter ws the length of BCI episode for our institution. Costs were obtined from the UAB Helth Services Foundtion. Study Outcomes The co-primry outcomes were the need for ICU dmission nd the use of mechnicl ventiltion in ptients who were included nd excluded from the BCI inititive bsed on DRG clssifiction. Secondry outcomes included index hospitl LOS, ICU LOS, in-hospitl mortlity, redmission rte, nd costs. Sttisticl Anlysis We used descriptive sttistics to compre the demogrphic nd clinicl chrcteristics between the DRG nd ICD-9 groups. Ech ctegoricl nd continuous vrible ws compred by c 2 nd independent smple t tests, respectively. Wilcoxon-rnk sum test ws used to compre costs to ccount for skewness. Aggregte costs of ll-cuse 30-dy nd 90-dy redmissions per ptient were clculted by summing the costs ech ptient incurred within 30 nd 90 dys from index hospitliztion dischrge. In similr secondry nlyses, we compred the DRG group with the ICD-9 group, excluding ptients with primry ICD-9 code of respirtory filure (518.81, 518.82, 518.84) from the ltter, s these ptients would be more likely to hve higher severity of illness. Finlly, we seprted the DRG cohort into ptients who hd n AE of COD ICD-9 code nd those who did not (dul coded vs DRG only) nd compred these 2 groups. This nlysis ws performed to provide informtion on the subgroup of ptients who my not truly hve COD, yet received COD DRG nd were therefore prt of the BCI inititive. All hypothesis testing ws 2-sided with significnce set t <.05. All nlyses were performed using SSS sttisticl softwre (version 22). RESULTS DRG Clssifiction nd Bseline Chrcteristics Of the 698 unique ptients included for nlysis, 459 were dischrged with COD DRG (DRG group) nd 239 were dischrged with non-cod DRG (ICD-9 group) (Tble 1). tients in the ICD-9 group more often were mle, were white, nd hd higher BMI ( <.05 for ll comprisons) compred with ptients in the DRG group. ICD-9 ptients lso hd lower rte of depression, jmc.com 12.17 / 13
Tble 1. Chrcteristics of tients Hospitlized With COD Excerbtion From 2012-2014 TOTAL (N = 698) DRG ICD-9 ONLY (n = 239) Femle, n (%) 370 (53.0) 263 (57.3) 107 (44.8).002 Age (yers), 68.6 (11.1) 68.87 (11.3) 68.0 (10.6).314 Rce, n (%) Blck White Other 245 (35.1) 447 (64.0) 6 (0.9) 175 (38.1) 282 (61.4) 2 (0.4) 70 (29.3) 165 (69.0) 4 (1.7) BMI (kg/m 2 ), 28.5 (11.4) 27.7 (8.2) 30.0 (15.9).013 Tobcco use, n (%) Never smoker Former smoker Current smoker Comorbidities, n (%) Depression Anxiety Hert filure Cirrhosis Dibetes Osteoporosis Chronic kidney disese Coronry rtery disese Lung cncer 96 (14.6) 360 (54.8) 201 (30.6) 117 (16.8) 79 (11.3) 122 (17.5) 12 (1.7) 173 (24.8) 68 (9.7) 72 (10.3) 129 (18.5) 30 (4.3) 73 (16.6) 234 (53.5) 132 (30.1) 93 (20.3) 59 (12.9) 78 (17.0) 8 (1.7) 119 (25.9) 53 (11.5) 54 (11.8) 101 (22.0) 22 (4.8) 23 (10.6) 126 (57.8) 69 (31.7) 24 (10.0) 20 (8.4) 44 (18.4) 4 (1.7) 54 (22.6) 15 (6.3) 18 (7.5) 28 (11.7) 8 (3.3).021.114.001.076.640.947.333.026.081.001.371 BMI indictes body mss index; COD, chronic obstructive pulmonry disese; DRG, dignosis-relted group; ICD-9, Interntionl Clssifiction of Diseses, Ninth Revision. Hospitl LOS nd Dischrge Disposition tients in the ICD-9 group hd higher rte of ICU dmission (63.2% vs 4.4%; <.001), longer ICU LOS (men = 5.2 [SD = 5.8] dys vs 1.8 [SD = 1.1] dys; =.011), nd longer hospitl LOS (10.3 [SD = 15.6] dys vs 3.9 [SD = 2.8] dys; <.001) compred with the DRG group (Tble 2). Thirty-five (14.6%) ptients in the ICD-9 group died during their index hospitliztion compred with 3 ptients (0.7%) in the DRG group ( <.001). ICD-9 ptients were less likely to be dischrged home thn those in the DRG group (37.7% vs 69.1%; <.001). Those in the subcohort of ICD-9 ptients without respirtory filure lso hd longer hospitl LOS (8.9 [SD = 6.4] dys vs 3.9 [SD = 2.8] dys; <.001), higher rte of ICU dmission (52.9% vs 4.4%; <.001), nd longer ICU LOS (4.0 [SD = 3.6] dys vs 1.8 [SD = 1.1] dys; =.008) compred with the DRG group. ICD-9 Medicre FFS-only ptients lso hd higher rtes of ICU dmission nd in-hospitl mortlity nd longer hospitl LOS. osteoporosis, nd coronry rtery disese. The most common DRG clssifictions for the ICD-9 group were pulmonry edem nd respirtory filure (DRG 189; n = 91) nd respirtory filure with ventiltor support less thn 96 hours (DRG 208; n = 71). hysiology nd Severity of Illness As shown in Tble 2, oxygen sturtion nd ph were lower nd prtil pressure of crbon dioxide nd respirtory rte were higher in the ICD-9 only group compred with the DRG group ( <.05 for ll), suggesting greter disese severity in the former. Likewise, ptients in the ICD-9 group hd higher rtes of NIV (46.9% vs 6.5%; <.001) nd invsive mechnicl ventiltion (41.4% vs 0.7%; <.001) during their index hospitliztion. tients in the ICD-9 group who did not hve code for respirtory filure nd hd primry ICD-9 code of 491.21 or 491.22 (n = 34) lso exhibited higher rte of use of NIV (35.3% vs 6.5%) nd invsive mechnicl ventiltion (32.4% vs 0.7%) compred with those in the DRG group ( <.001 for both). When we restricted our nlysis to fee-forservice Medicre ptients, we found similr differences in the use of NIV nd mechnicl ventiltion between the DRG (n = 276) nd ICD-9 (n = 166) groups. Redmission tterns nd Cost Utiliztion There were no sttisticlly significnt differences in 30- or 90-dy ll-cuse redmission rtes between the 2 groups (Tble 3). The ICD-9 group hd higher totl medin cost of index hospitliztion thn the DRG group (medin = $13,677 [interqurtile rnge = $7489-$23,054] vs $4281 [$2718-$6537]; <.001). Totl costs of index dmission in the ICD-9 group, excluding respirtory filure codes, were lso significntly higher thn costs in the DRG group ($15,793 [$10,890-$23,590]; <.001). Aggregte costs per ptient incurred in the 30 nd 90 dys fter index hospitliztion dischrge were higher in the ICD-9 group compred with the DRG group (men = $3122 [SD = $12,564] vs $1667 [SD = $5872] in 30 dys; $5376 [SD = $14,882] vs $4116 [SD = $10,493] in 90 dys) (Tble 3). Of the 459 ptients who were included in the COD DRG group, 115 did not hve COD ICD-9 code. Their clinicl chrcteristics, severity of illness, nd redmissions were similr to others included in the COD DRG. tients in the DRG-only group, however, did hve longer hospitl LOS (men = 4.5 [SD = 3.2] dys vs 3.7 [SD = 2.8] dys; =.013) nd costlier index dmission ($5172 [$3220- $7129] vs $4013 [$2651-$6204]; =.004) (Tbles 4 nd 5). 14 / 12.17 The Americn Journl of Accountble Cre
Tble 2. Comprison of Severity of Illness for Index Admission DRG ICD-9 (n = 239) Respirtory rte, 20.8 (3.9) 22.2 (7.4).001 SpO 2, 94.4 (5.2) 93.0 (9.8).010 ph, 7.4 (0.1) 7.36 (0.1).026 pco 2, 47 (11.9) 59 (21.9) <.001 NIV in hospitl, n (%) 30 (6.5) 112 (46.9) <.001 Intubtion, n (%) 3 (0.7) 99 (41.4) <.001 Hospitl length of sty (dys), 3.9 (2.8) 10.3 (15.6) <.001 ICU dmission, n (%) 20 (4.4) 151 (63.2) <.001 ICU length of sty (dys), 1.8 (1.1) 5.2 (5.8).011 Disposition, n (%) Home SNF Home helth In-hospitl deth 317 (69.1) 30 (6.5) 86 (18.7) 3 (0.7) 90 (37.7) 34 (14.2) 50 (20.9) 35 (14.6) DISCUSSION We show tht there is significnt vrition in the clinicl chrcteristics, outcomes, nd costs of ptients hospitlized with AEs of COD who re nd re not included in the COD BCI inititive. More thn one-third of ptients with n ICD-9 dignosis of AE of COD were excluded from the inititive despite hving higher severity of <.001 Home oxygen use on dischrge, n (%) 21 (4.6) 19 (9.3).019 DRG indictes dignosis-relted group; ICD-9, Interntionl Clssifiction of Diseses, Ninth Revision; ICU, intensive cre unit; NIV, noninvsive positive pressure ventiltion; pco 2, prtil pressure of crbon dioxide; SNF, skilled nursing fcility; SpO 2, oxygen sturtion. Arteril blood gs obtined on 45/459 (9.8%) of DRG group nd 167/239 (70%) of ICD-9 group ( <.001). Tble 3. Cost of Index Admission nd Redmissions Totl index hospitliztion cost medin (IQR) Aggregte cost of 30-dy redmissions per ptient (n = 660) Aggregte cost of 90-dy redmissions per ptient b (n = 660) DRG $5181 ($3437) $4281 ($2718- $6537) $1667 ($5872) $4116 ($10,493) ICD-9 (n = 239) $23,153 ($55,062) $13,677 ($7489- $23,054) $3122 ($12,564) $5376 ($14,882) <.001.004 <.001 DRG indictes dignosis-relted group; ICD-9, Interntionl Clssifiction of Diseses, Ninth Revision; IQR, interqurtile rnge. 30-dy ll-cuse redmissions: 65/456 (14.3%) in DRG versus 40/204 (19.7%) in ICD-9 ( =.080). b 90-dy ll-cuse redmissions: 122/456 (26.8%) in DRG versus 63/204 (31.0%) in ICD-9 ( =.266). illness, greter ICU utiliztion, longer hospitl nd ICU LOS, nd incresed likelihood of mortlity. Despite hving ICD-9 codes for n AE of COD, these ptients were given wide rnge of non-cod DRG clssifictions, which confirms the heterogeneity of the group excluded from the bundled pyment inititive. These ptients did not receive the dditionl interventions reserved for those included in the progrm, nd the institution is neither incentivized for improved outcomes nor penlized for incresed costs in this group. Our findings show tht the current system bsed on COD DRGs excludes lrge number of ptients with COD nd respirtory filure who would potentilly benefit from these interventions. tients in the DRG group hd significntly lower nd less skewed totl cost of index hospitliztion thn ptients in the ICD-9 group. This cn be explined by the incresed resource utiliztion in the ICD-9 group, s these ptients hd longer LOS nd more dys in the ICU. By excluding these ptients from the COD DRG, Medicre imed to estblish cliniclly homogeneous group of ptients with similr resource utiliztion, 8 nd our dt show tht Medicre ws successful in reching this gol. This cn benefit BCI inititive prticipnts by relieving the finncil pressures cused by pying for more severely ill ptients in which resource utiliztion is unvoidble. However, this lso prevents these sicker ptients from receiving postcute cre tht my be beneficil. In ddition, one-fourth of ptients ssigned to COD DRG did not hve n ICD-9 dignosis of AE of COD nd were more likely to be dmitted for other diseses. These ptients hd longer hospitl LOS nd higher index dmission costs, perhps becuse their disese process is not directly ddressed by the COD-specific interventions provided through the BCI inititive. Institutions should be mindful of potentil misclssifictions, s they will be finncilly responsible for ll ptients who re ssigned to the BCI. Misclssifiction of non-cod ptients will lso dilute resources intended for ptients with COD, mking the evlution of ny COD-focused intervention difficult. Our study results not only highlight the differences between the DRG nd ICD-9 groups, but lso shed light on the implictions of prticiption in the BCI inititive. In resource-limited helthcre setting, we were unble to provide COD-focused interventions nd trnsitionl cre services for ll ptients with the disese. Our resources were necessrily trgeted to those ptients with COD for whom we were held finncilly responsible s defined by the BCI. Although excluded ptients my benefit from the BCI interventions, nd both we nd other providers often felt strongly tht they ought to be included, we did not hve the cpcity to ccommodte ptients for whom we did not crry finncil responsibility. This jmc.com 12.17 / 15
Tble 4. Clinicl Chrcteristics of Dul-Coded nd DRG tients With COD Tble 5. Cost of Index Admission nd Redmissions of Dul-Coded nd DRG tients With COD Totl hospitliztion cost medin (IQR) DUAL-CODED (n = 344) DUAL-CODED (n = 344) $4916 ($3184) $4013 ($2651-$6204) DRG ONLY (n = 115) Respirtory rte on dmission, 20.6 (3.9) 21.3 (3.8).099 SpO 2 on dmission, 94.4 (5.1) 94.5 (5.6).847 ph, 7.40 (0.1) 7.39 (0.1).790 pco 2, 47.8 (12.6) 45.3 (9.5).154 NIV in hospitl, n (%) 24 (7.0) 6 (5.2).509 Intubtion, n (%) 3 (0.9) 0 (0.0).315 Hospitl length of sty (dys), 3.72 (2.8) 4.49 (3.2).013 ICU dmission, n (%) 16 (4.7) 4 (3.5).594 ICU length of sty (dys), 2.1 (1.3) 1.2 (0.4).227 Disposition, n (%) Home SNF Home helth In-hospitl deth 233 (67.7) 24 (7.0) 68 (19.8) 1 (0.3) 84 (73.0) 6 (5.2) 18 (15.7) 2 (1.7) DRG ONLY (n = 115) $5973 ($4013) $5172 ($3220-$7129) Aggregte cost of 30-dy redmission per ptient b (n = 456) $1810 ($6432) $1231 ($3676) Aggregte cost of 90-dy redmission per ptient c (n = 456) $4010 ($10,561) $4437 ($10,323) COD indictes chronic obstructive pulmonry disese; DRG, dignosis-relted group; IQR, interqurtile rnge. tients who hd DRG of 190-192 nd non-cod Interntionl Clssifiction of Diseses, Ninth Revision code. b 30-dy ll-cuse redmissions: 49/343 (14.3%) in dul-coded versus 16/113 (14.2%) in DRG-only group ( =.973). c 90-dy ll-cuse redmissions: 88/343 (25.7%) in dul-coded versus 34/113(30.1) in DRG-only group ( =.356). exclusion ws disconcerting to both the pulmonologists involved with the progrm nd the referring providers. Multiple vribles re used to plce n episode of cre into specific DRG. In n Austrlin study reviewing clinicl documenttion for impct on DRG lloction, Chin et l found tht 48% of reviewed summries resulted in ressignment of DRG nd reimbursement increse of $142,000 Austrlin dollrs, with the most.352 Home oxygen use on dischrge, n (%) 17 (4.9) 4 (3.5).516 COD indictes chronic obstructive pulmonry disese; DRG, dignosis-relted group; ICU, intensive cre unit; NIV, non-invsive positive pressure ventiltion; pco 2, prtil pressure of crbon dioxide; SNF, skilled nursing fcility; SpO 2, oxygen sturtion. tients who hd DRG of 190-192 nd non-cod Interntionl Clssifiction of Diseses, Ninth Revision code..004.825.363 coding vrince seen in respirtory infections. 9 Another study evluted 2 episode-cretion lgorithms for dibetes nd coronry rtery disese nd found tht ech method identified different ptients with the 2 conditions. For dibetes, the 2 methods resulted in mrkedly different pyments, with one cpturing 69% of totl dibetes-relted pyments nd the other only 20%. 10 These studies highlight the potentil for misclssifiction nd misdignosis, s well s the finncil impct tht DRG clssifiction cn hve on prticipnts in the BCI inititive. In order for the BCI inititive to be successful, ptients who re correctly clssified into DRG code should lso receive cost-sving interventions tht result in higher qulity of cre nd fewer redmissions. By pying fixed mount for n episode of cre, Medicre presents prticipting institutions with the chllenge of finding less expensive, fster, nd more effective wy to deliver cre tht does not come t greter expense. Although there hve been numerous studies evluting the predictors of COD redmissions, 11-13 there re currently no interventions tht hve been specificlly demonstrted to reduce these redmissions. 14 Some studies hve shown tht integrted disese mngement interventions cn led to improvement in disese-specific qulity of life nd reduction in hospitl dmissions 15 ; however, these findings re not consistently reported 16 nd the long-term effectiveness of these interventions is unknown. revious studies hve evluted BCI prticipnts in nonspine surgicl orthopedic episodes nd found reduced LOS, fewer dischrges to postcute cre units, nd fewer redmissions compred with non-bci prticipnts. 17,18 The findings of recent study evluting more thn 30,000 lower extremity joint replcement episodes dd confirmtory evidence tht the BCI inititive is successful in reducing Medicre pyments while preserving qulity of cre for orthopedic episodes. 19 Hip nd knee rthroplsty were idel tretments to evlute erly trils of bundled pyments; however, the extension of episode-bsed pyment to chronic diseses presents new chllenges. Episodes for chronic conditions, including COD, congestive hert filure, nd end-stge renl disese, hve clinicl trjectory tht is drmticlly different from tht of elective surgicl procedures. tients with chronic diseses cn present with 16 / 12.17 The Americn Journl of Accountble Cre
multiple interrelted conditions tht require coordinted nd long-term mngement. 20 This complictes the DRG clssifiction of specific episode nd cn dd to the heterogeneity of ptients in single DRG or misclssifiction of ptients to n lterntive DRG, s ws seen with one-fourth of ptients in our cohort. In ddition, fr greter cost vribility hs been observed in ptients with COD nd stroke compred with lower extremity joint replcement nd hip frcture, which plces providers nd institutions t higher finncil risk when volunteering for BCI inititive for these conditions. 21 Limittions Our study hs severl limittions. First, the selection of ptients ws bsed on ICD-9 nd DRG coding to determine episodes of AEs of COD, which my not ccurtely reflect the reson for dmission. 22 The purpose of this study ws to evlute clssifiction system bsed on medicl records documenttion nd dministrtive coding; therefore, the uthenticity of COD in ech ptient ws not confirmed by evidence of irflow obstruction on pulmonry function testing. This process reflects the rel-world cse determintion processes medicl center nd CMS would utilize to identify ptients qulifying for the BCI. Second, we cknowledge tht inclusion of respirtory filure ICD-9 codes ccounted for some of the observed differences between the ICD-9 nd DRG groups. However, we found similr results in our subgroup nlysis excluding respirtory filure codes from the ICD-9 group. Third, our single center study hd reltively smll smple size, which reduced its power. Despite this, we did observe number of sttisticlly nd cliniclly significnt differences between the chrcteristics nd outcomes of the ICD-9 nd DRG groups, which we believe provide importnt informtion. Finlly, we did not hve ccess to outptient cost dt, which is known to contribute to cost vribility. 23 CONCLUSIONS The sole use of DRGs to identify COD excerbtions led to the exclusion of over one-third of ptients with AEs of COD who hd more severe illness nd worse outcomes nd my benefit most from the dditionl interventions provided by bundled pyment inititives. In ddition, this pproch led to the misclssifiction of ptients without COD in the BCI inititive (one-fourth of the totl) who utilized resources intended for ptients with COD. Comprehensive dt from implementtion of the BCI inititive cross rnge of chronic diseses will not be vilble for severl yers; however, the current study provides new informtion to future BCI inititive prticipnts bout the progrm s design nd potentil consequences for COD reimbursement nd qulity of cre. Exclusion of the sickest ptients from the BCI inititive presents n ethicl nd logisticl predicment for helthcre professionls. Alterntive strtegies should be explored to mximize the benefits of the inititive for chronic diseses like COD, including the development of bundled pyment model tht includes respirtory filure. Author Affilitions: Deprtment of Medicine (TM, SB, JMW, dk, ASI, MM, JHW, MTD), nd Division of ulmonry, Allergy, nd Criticl Cre (TM, SB, JMW, dk, ASI, MTD), nd Division of Infectious Diseses (MM, JHW), University of Albm t Birminghm, Birminghm, AL; UAB Lung Helth Center (TM, SB, JMW, dk, ASI, MTD), Birminghm, AL; Deprtment of Biosttistics (AOW), nd Deprtment of Helth Behvior (MM), University of Albm School of ublic Helth, Birminghm, AL; Birminghm VA Medicl Center (JMW, MTD), Birminghm, AL. Source of Funding: None. Author Disclosures: Dr Iyer reports receiving grnt # T32HS013852 from the Agency for Helthcre Reserch nd Qulity nd n institutionl Ruth L. Kirschtein Ntionl Reserch Service Awrd. Dr Bhtt reports funding from NIH K23HL133438. Dr Wells reports receiving grnts from NIH/NHLBI K08 HL123940, the Cystic Fibrosis Foundtion SORSCH15R0, contrcts with GlxoSmithKline nd AstrZenec for conducting clinicl trils, nd other funding from AstrZenec. Dr Mugvero received consulting fees for scientific dvisory bord for Giled nd Bristol-Myers Squibb nd grnt funding (to UAB) from Bristol-Myers Squibb. Dr Drnsfield reports receiving grnts from the NIH, Deprtment of Defense, nd the Americn Hert Assocition; personl fees nd other funding from Astr Zenec, Boehringer Ingelheim, Boston Scientific, Genentech nd GlxoSmithKline; nd other funding from erl, ulmonx, neumrx, AstrZenec, Novrtis, nd Yungjin. The remining uthors report no reltionship or finncil interest with ny entity tht would pose conflict of interest with the subject mtter of this rticle. resenttion: This work ws submitted for presenttion t the Americn Thorcic Society Conference in Sn Frncisco, Cliforni in My 2016. Authorship Informtion: Concept nd design (TM, dk, ASI, MM, JHW, MTD); cquisition of dt (TM, SB, ASI, JHW, MTD); nlysis nd interprettion of dt (TM, AOW, JMW, ASI, MTD); drfting of the mnuscript (TM, AOW, JMW, ASI, JHW, MTD); criticl revision of the mnuscript for importnt intellectul content (TM, SB, AOW, JMW, dk, MM, JHW, MTD); sttisticl nlysis (TM, AOW); provision of study mterils or ptients (SB, dk); dministrtive, technicl, or logistic support (MM, MTD); nd supervision (SB, JHW, MTD). Send Correspondence to: Trish rekh, DO, University of Albm t Birminghm, 1900 University Blvd, THT 428, Birminghm, AL 35233. E-mil: trishprekh@ubmc.edu. jmc.com 12.17 / 17
REFERENCES 1. Burwell SM. Setting vlue-bsed pyment gols HHS efforts to improve U.S. helth cre. N Engl J Med. 2015;372(10):897-899. doi: 10.1056/NEJMp1500445. 2. Bundled yments for Cre Improvement (BCI) inititive: generl informtion. CMS website. innovtion.cms.gov/inititives/bundled-pyments. Updted September 29, 2017. Accessed Jnury 18, 2016. 3. Innovtors guide to nvigting Medicre. CMS website. innovtion.cms.gov/files/reports/innovtors-guide-to-medicre.pdf. ublished 2010. Accessed Jnury 18, 2016. 4. Kirkptrick D, Wells JM, Bhtt S, Tucker R, Lech L, Drnsfield MT. A novel pproch to reducing 90-dy redmission rtes for ptients with AECOD. Am J Respir Crit Cre Med. 2015;191:A1102. tsjournls.org/doi/bs/10.1164/jrccm-conference.2015.191.1 _MeetingAbstrcts.A1102. Accessed Mrch 24, 2016. 5. Drnsfield MT, Rowe SM, Johnson JE, Biley WC, Gerld LB. Use of bet blockers nd the risk of deth in hospitlised ptients with cute excerbtions of COD. Thorx. 2008;63(4):301-305. doi: 10.1136/thx.2007.081893. 6. Stein BD, Chrbeneu JT, Lee TA, et l. Hospitliztions for cute excerbtions of chronic obstructive pulmonry disese: how you count mtters. COD. 2010;7(3):164-171. doi: 10.3109/15412555.2010.481696. 7. Feemster LC, Au DH. enlizing hospitls for chronic obstructive pulmonry disese redmissions. Am J Respir Crit Cre Med. 2014;189(6):634-639. doi: 10.1164/rccm.201308-1541. 8. Acute Cre Hospitl Inptient rospective yment System. CMS website. cms.gov/outrech-nd-eduction/medicre-lerning- Network-MLN/MLNroducts/downlods/AcuteymtSysfctsht.pdf. ublished April 2013. Accessed Mrch 4, 2016. 9. Chin N, erer, Roberts A, Ngppn R. Review of medicl dischrge summries nd medicl documenttion in metropolitn hospitl: impct on dignostic-relted groups nd Weighted Inlier Equivlent Seprtion. Intern Med J. 2013;43(7):767-771. doi: 10.1111/imj.12084. 10. O Byrne TJ, Shh ND, Wood D, et l. Episode-bsed pyment: evluting the impct on chronic conditions. Medicre Medicid Res Rev. 2013;3(3). doi: 10.5600/mmrr.003.03.07. 11. Yu TC, Zhou H, Suh K, Arcon S. Assessing the importnce of predictors in unplnned hospitl redmissions for chronic obstructive pulmonry disese. Clinicoecon Outcomes Res. 2015;7:37-51. doi: 10.2147/CEOR.S74181. 12. Grci-Aymerich J, Hernndez C, Alonso A, et l. Effects of n integrted cre intervention on risk fctors of COD redmission. Respir Med. 2007;101(7):1462-1469. doi: 10.1016/j. rmed.2007.01.012. 13. Shrif R, rekh TM, ierson KS, Kuo YF, Shrm G. redictors of erly redmission mong ptients 40 to 64 yers of ge hospitlized for chronic obstructive pulmonry disese. Ann Am Thorc Soc. 2014;11(5):685-694. doi: 10.1513/AnnlsATS.201310-358OC. 14. rieto-centurion V, Mrkos MA, Rmey NI, et l. Interventions to reduce rehospitliztions fter chronic obstructive pulmonry disese excerbtions. systemtic review. Ann Am Thorc Soc. 2014;11(3):417-424. doi: 10.1513/AnnlsATS.201308-254OC. 15. Kruis AL, Smidt N, Assendelft WJ, et l. Integrted disese mngement interventions for ptients with chronic obstructive pulmonry disese. Cochrne Dtbse Syst Rev. 2013;10:CD009437. doi: 10.1002/14651858.CD009437.pub2. 16. Fn VS, Gzino JM, Lew R, et l. A comprehensive cre mngement progrm to prevent chronic obstructive pulmonry disese hospitliztions: rndomized, controlled tril. Ann Intern Med. 2012;156(10):673-683. doi: 10.7326/0003-4819-156-10-201205150-00003. 17. The Lewin Group. CMS Bundled yments for Cre Improvement (BCI) inititive Models 2-4: Yer 1 evlution nd monitoring nnul report. CMS website. innovtion.cms.gov/files/ reports/bci-evlrpt1.pdf. ublished Februry 2015. Accessed Jnury 18, 2016. 18. Iorio R, Clir AJ, Inneh IA, Slover JD, Bosco JA, Zuckermn JD. Erly results of Medicre s Bundled yment inititive for 90-dy totl joint rthroplsty episode of cre. J Arthroplsty. 2016;31(2):343-350. doi: 10.1016/j.rth.2015.09.004. 19. Dummit LA, Khvecioglu D, Mrrufo G, et l. Assocition between hospitl prticiption in Medicre bundled pyment inititive nd pyments nd qulity outcomes for lower extremity joint replcement episodes. JAMA. 2016;316(12):1267-1278. doi: 10.1001/jm.2016.12717. 20. Hussey S, Sorbero ME, Mehrotr A, Liu H, Dmberg CL. Episode-bsed performnce mesurement nd pyment: mking it relity. Helth Aff (Millwood). 2009;28(5):1406-1417. doi: 10.1377/hlthff.28.5.1406. 21. Sood N, Huckfeldt J, Escrce JJ, Grbowski DC, Newhouse J. Medicre s bundled pyment pilot for cute nd postcute cre: nlysis nd recommendtions on where to begin. Helth Aff (Millwood). 2011;30(9):1708-1717. doi: 10.1377/hlthff.2010.0394. 22. Stein BD, Butist A, Schumock GT, et l. The vlidity of Interntionl Clssifiction of Diseses, Ninth Revision, Clinicl Modifiction dignosis codes for identifying ptients hospitlized for COD excerbtions. Chest. 2012;141(1):87-93. doi: 10.1378/chest.11-0024. 23. Tsi TC, Joynt KE, Wild RC, Orv EJ, Jh AK. Medicre s Bundled yment inititive: most hospitls re focused on few high-volume conditions. Helth Aff (Millwood). 2015;34(3):371-380. doi: 10.1377/hlthff.2014.0900. 18 / 12.17 The Americn Journl of Accountble Cre