Case 2010-MDC01-02 Implantation of vagus nerve stimulator
|Target version:||Expert Group 2010|
|MDC:||MDC01||Owner / responsible:|
|Target Grouper:||SWE||Old forum status:||CLOSITEM - Closed item|
Last updated: 2010-04-09
Status: CLOSITEM - Closed item
By: Laura Lüdtke (email@example.com)/CPK, Sweden
Expert Network 2010-03-12 - Change recommended
Board 2010-04-09 - Recommendation accepted
CPK ID 327
Vagus nerve stimulation (VNS) is an alternative treatment for patients with refractory epilepsy who are unsuitable for epilepsy surgery. There are about 100 VNS interventions performed yearly in Sweden. The number of interventions has been increasing with a couple of cases yearly and this increase is likely to continue for the coming years.
The vagus nerve stimulator is an implantable, multiprogrammable pulse generator that delivers continuously intermittent electrical signals to the vagus nerve. An external programming system is used to change stimulation settings. Implantation takes 1-2 hours, generally under general anaesthesia, and the procedure may involve an overnight stay to monitor the patient. The cost for the stimulation system is 155 000 to 175 000 SEK and the total cost for the hospital is approximately 206 000 SEK. The procedure is coded with ADB00 (Inläggande av vagusnervsstimuleringsutrustning) and grouped to DRG 007/008 (Op på hjärnnerver & andra delar av nervsystemet, komplicerat / ej komplicerat).
The pulse generator has to be changed after 6-8 years. This requires an additional surgical procedure, involving anaesthesia, which generally takes less than an hour to complete. The cost for the new generator is 120 000 to 140 000 SEK and the total cost for the hospital is approximately 180 000 SEK.. This procedure is coded with AEA00 (Byte av impulsgenerator i stimuleringsutrustning i nervsystemet) and is also grouped to DRG 007/008.
The national weights 2010 for DRG 007 and 008 are 1,9009 and 1,0455 respectively which represent cost levels of approximately 76 000 SEK and 42 000 SEK. Thus, ADB00 and AEA00 are much more expensive than the average costs for DRG 007 and 008 and a separate DRG for ADB00 and AEA00 is proposed.
(The problem description has been shortened by Mats Fernström at CPK)
Analysis by CPK
The analysis was performed on the material in the Swedish cost database for inpatients 2008.
There were only 41 cases with ADB00 in DRG 007/008 (see table below) and most of them (34 cases) were cost outliers in DRG 008.
The average cost for these 41 cases is 163 000 SEK which is less than the amount given by the initiator (206 000 SEK). This can be explained by the 33 % discount given on the device so far, but the discount will cease 2010 according to the initiator.
There were 185 cases with AEA00 in DRG 007/008 (see table below) and most of them were not cost outliers.
The average cost for these 185 cases is 89 000 SEK which is far less than the amount given by the initiator (180 000 SEK). This can partly be explained by the 33 % discount given on the device so far but also by the fact that AEA00 is used also for replacement of cheaper devices like the spinal cord stimulation system used for chronic pain (described in CPK ID 297). Furthermore, the cost data for replacements are probably underestimated. The reported minimum costs (see table above) clearly shows that the device cost is not included.
The number of cases with ADB00 is so far too small to be a separate DRG but it could be possible to create a new DRG for ADB00 plus AEA00 as suggested by the initiator. According to our cost data (probably underestimated) there will be 226 cases with the average cost 103 000 SEK.
There are related procedures that also are grouped to DRG 007/008. They are not enough expensive to be included in the new DRG, however. See the tables below.
The tables below show what will happen with DRG 007/008 if we remove ADB00 and AEA00.
In DRG 007 the number of cases is reduced from 288 to 268, a reduction with 20 cases (7 %), both in the un-trimmed and the trimmed material. The average cost in the un-trimmed material is almost unchanged and reduced from 76 640 to 73 338 SEK, a reduction with 3 302 SEK (4 %) in the trimmed material.
In DRG 008, in the un-trimmed material, the number of cases is reduced from 1 693 to 1 487, a reduction with 206 cases (12 %) and the average cost is reduced from 49 834 to 42 722 SEK, a reduction with 7 112 SEK (14 %). In the trimmed material number of cases is reduced from 1 598 to 1 438, a reduction with 160 cases (10 %) and the average cost is reduced from 41 724 to 37 221 SEK, a reduction with 4 503 SEK (11 %). Thus, the changes in DRG 007/008 are rather small.
We support the idea of creating a new DRG for ADB00 and AEA00 but the group should preferably also include ABD30 (Inläggande av spinal stimuleringsutrustning) that is described in CPK ID 297. According to our cost data there will then be 641 cases with the average cost 82 000 SEK but then one must consider that cost data probably are underestimated for both ABD30 and AEA00.
For the moment we don’t propose to include the codes for intracranial stimulation devices since these procedures demand a craniotomy and we have not calculated on the costs for these procedures.
The new DRG could have the text “Implantation or replacement of stimulation device in the nervous system”. The DRG should be placed in MDC 01 and the grouping rule should be placed immediately before the rule for DRG 007 but, for simplicity, the rule should accept any ICD10 code as primary diagnosis.
This new DRG should also have a corresponding group for outpatients. The most important reason is that these cases also are spread over several DRGs with the present logic. The number of outpatients is still rather small (52 cases in the Swedish cost database for outpatients 2008) but it will probably increase in the coming years.
Recommendation by CPK
A new DRG for ADB00, AEA00 and ABD30 as described above.
Expert Network 2010-03-12
The meeting recommended accepting the proposal to create a new DRG for ADB00, AEA00 and ABD30.
For technical change see .