Case 2012-MDC03-01 Dental care DRG's for NordDRG
|Target version:||Expert Group 2012|
|Case type:||Major||Owner / responsible:||National organisations|
|MDC:||MDC03||Old forum status:||CLOSITEM - Closed item|
|Target Grouper:||COMMON, DEN, EST, FIN, ICE, LAT, NOR, SWE|
Last updated: 2012-11-01
Status: CLOSITEM - Closed item
By: Finnish expert group on Dentistry, Finnish national DRG Centre, FCG
Expert Network 2012-03-08 - Changed recommended
Board 2012-03-19 - Recommendation accepted
Case 2008-MDC03-02 Hospital level toothcare
Finland proposed 4 years ago a modification to the DRG’s for hospital level secondary care dentistry. The model was not accepted by the other countries but it has since then been used in the Finnish NordDRG version. The clinical community has not been satisfied with the system and several demands for a new version have been sent to Finnish national DRG Centre.
In the spring 2010 a group of dentist’s from all university hospitals was formed to produce a common proposal from Finland.
In Finland all University hospitals have extensive hospital level (secondary or tertiary care) dentist services. Central Finland central hospital (Jyväskylä) has also extensive services but other central hospitals have clearly less extensive services.
Finland has had an extension of NCSP for dental interventions for more than 10 years. This part of the classification is in active by dentists both at hospitals and in primary dental care in health centers and in private practices.
For this work we used clinical data from all university hospitals except Tampere and from Central Finland.
The work was initiated by listing dental and mouth interventions in 4 groups as well as radiological interventions in four groups. This work was done by clinicians in the group. The data was but to an excel book were the interventions performed to the patients were given properties according to the new list of properties. The patient were assigned the heaviest intervention and heavies radiological intervention class and additionally indicated the presence or absence of general anesthesia. This is general anesthesia not including other extensive anesthesia forms!
Based on data a matrix of groups was formed that is demonstrated as the second sheet of the Excel presentation. Variance measured by V% became in most groups acceptable, although some problems remain.
The proposed model has only one group for only inpatients – the group without any significant intervention is divided in inpatients and short therapy patients. All other groups are formed irrespective of the length of stay because the intervention are far more important determinants of the resource use. For this reason the rules are placed in outpatient area of the grouper but without any defined rule for length of stay.
The data is taken from the Dental departments of the hospitals (specialty code 58). However, not all have dental code (dgcat 03M99) as principal diagnosis. This due partly to the fact that many cases not coded correctly – a dental diagnosis exists in the data but it is not principal dg. Therefore we use the whole data in the analysis, assuming that this is just an error of coding. In the grouper this would however not be the case and the patients would be partly assigned to other areas of DRG system.
There are also cases where the principal dg is related to dental problems and obviously correctly coded. For intervention cases this can be corrected by assigning the cases using a principal diagnosis property (pdgprop 03P01, new) and post MDC rules (in short therapy part of the DRG logic). For cases without significant interventions this is not possible, because they will be assigned by the diagnosis category of the code at issue. The problem is minor since these cases are not high resource cases and the nature of the problem is actually quite well described by the diagnosis category.
The proposal is mainly described on the first sheet of the attached Excel-book where the groups, the proposed rules and the analysis of the cost distribution is included.
The second sheet is the matrix of the new groups which has been used in the developmental work.
The third sheet is short version of the data where most of the information has been removed.
The fourth sheet is the list of intervention codes and the properties given to them (including the proposal for new properties to be used in the grouper)
The fifth sheet give the names of the new properties (English and for some reason Finnish).
The sixth sheet lists the diagnoses that need either a change of diagnosis category or a new principal diagnosis property. Please observe that all changes of category are for Finnish subcodes on 5th character level.
Expert Network 2012-03-08
Finland has worked with this problem a long time now. This solution is planned to be introduced in Finland 2013. Martti informs about the solution, for more information see NordDRG Forum.
In Sweden it must be useful also for the private dentists, not only for hospital dental surgery. For Sweden it is necessary with new procedure codes otherwise it is impossible to implement it.
Finland is asked to report the results of this new suggestion as soon as possible so that it might be introduced in the rest of the Nordic countries.
The case will be closed.
Martti Virtanen 2012-09-13
It was noticed that cases with dental interventions and for example transplantations will be assigned to dental groups in hospital care because the rules for dental care are located among short therapy groups i.e. before hospital care preMDC rules.
To avoid this, the rules located in the preMDC area will be modified to apply only for short therapy cases. The original rules (without short therapy restriction) will be repeated in classical rule area (ord 403D… and 491D.l..) for assignment of inpatient cases. The DRG’s will still be the same both for short therapy and inpatient care.
Martti Virtanen 2012-09-28
The proposed change for the Finnish grouper has a few mistakes. First since the dental logic is situated in short therapy area of the logic, in inpatient care it will take precedence also for example to transplant surgery. This is not acceptable. To avoid it, there need to be separate rules for short therapy cases and for inpatient cases although the groups are the same. Both sets of rules are place within the MDC 03 rules (either in short therapy area or in inpatient area of the logic table).
Second it turned out that the placement in short therapy area was incorrect since after the change the rules became almost unusable. They had to be place before the current rule 103D02000 for DRG 063O using the procedure property 03S12 ‘Other ear, nose, mouth and throat OR procedure’. There is large overlap between 03S12 and the new dental intervention properties. The result is that most of the major interventions in the DRG 063O (and 063 in inpatient care) will be assigned to new dental DRG’s based on the new evaluation of their resource use. For inpatients the correction position of the dental rules is similarly before the rule for DRG 063.
The DRG’s 168 and 169 ‘Mouth procedures’, w cc or w/o cc, have become obsolete in the Finnish model since they are logically substituted by the new dental groups. There is obviously a 100% overlap of the property 03S05 with the new dental intervention properties. Thus the rules for DRG’s 168 and 169 must be deleted.
There is complete or almost overlap between the properties 03S04 ‘Cleft lip and palate repair’, 03S08 ‘Parotidectomy‘ and 03S09 ‘Salivary gland procedure except parotidectomy’ with the new dental rules. To avoid grouping of define ENM cases to dental groups the rules using these properties need to be placed before the dental groups. To avoid unnecessary changes in the order of the surgical rules in the MDC 03, all rules for theDRG’s 052A, 052B, 055, 053A, 053B, 056 and 050N are placed before the dental rules.
The procedure property 03S01 ‘Major head and neck procedures’ has some overlap with the dental procedure properties. However, the group 03S01 is already an extremely resource intensive group and it is neither possible to allow the dental groups to take precedence over this group. Therefore the rule for DRG 049A will remain before the dental rules at the top of the MDC 03 rules.
The effect of this modification is that number of cases moving from the ENM-DRG’s to dental DRG’s within MDC 03 is diminished. This phenomenon was observed but not understood correctly in the Finnish testing of the planning version.
2012-07-30 Minna-Liisa Sjöblom