Case #368

Introducing new DRGs for cases with ischemic stroke in case i/v thrombolytic treatment is performed

Added by Kristiina Kahur over 4 years ago. Updated about 3 years ago.

Status:AcceptedStart date:2015-01-24
Priority:MajorSpent time:-
Assignee:Kristiina Kahur
Category:-
Target version:Expert Group 2015
Initiator:Estonia Target year:2016
Case type:Major Owner / responsible:National organisations
MDC:MDC01 Old forum status:
Target Grouper:EST

Description

The current NordDRG logic rules do not take into account the use of intravenous thrombolytic therapy (ITT) in case of acute ischemic stroke and therefore the patients with cerebral infarction (dx codes I630-I639) are assigned to the same DRG as the patients with acute ischemic stroke without ITT. The DRGs concerned are:
DRG14A Specific cerebrovascular disorders except TIA with cc, and
DRG 14B Specific cerebrovascular disorders except TIA w/o cc)

For ITT tissue plasminogen activator is used and it creates additional use of resources for health care providers. Whereas patients without ITT are less expensive. It has created some concerns and dissatisfaction among health care providers performing ITT and initiated the process of changing the DRG logic.

As the first step, specific NCSP code was introduced to Estonian NCSP version in 2014 – AAL18 (Intravenous fibrinolytic therapy for acute ischemic stroke) – to give to providers opportunity to start to code ITT and also educate in proper coding. As a remark, there is also alternative ITT code in use for reimbursement purpose in Estonia which has allowed to gather the information about using ITT in case of acute ischemic stroke from previous years already. Nevertheless, this code cannot be used in DGR logic and therefore respective NCSP code had to be introduced.
The cost analysis was performed with aim to see the differences in costs depending on the use of ITT. For analysis the billing information from Estonian Health Insurance Fund’s database of years 2013 and 2014 was used. The cases with cost less than 500EUR were excluded from data.

The results, as anticipated, clearly showed the difference within DRGs 14A and 14B depending on the use of ITT. As average, the cases with ITT were 76% more expensive in DRG 14A and the respective value in DRG 14B was 87% (2014). Similar values were observed among 2013 data. More information is provided in Appendix 1.

The proposal:
To create two new DRGs: 14C and 14D.
DRG14C: The cases with main diagnosis code among I630-I639, NCSP code AAL18, and secondary diagnoses with CC property.
DRG 14D: The cases with main diagnosis code among I630-I639, NCSP code AAL18, and secondary diagnoses without CC property.
As a consequence, the names of current 14A and 14B have to be corrected. Two corrected and two new DRG names would be as follows:
14A Specific cerebrovascular disorders except TIA without i/v thrombolytic therapy with cc
14B Specific cerebrovascular disorders except TIA without i/v thrombolytic without cc
14C Specific cerebrovascular disorders except TIA with i/v thrombolytic therapy with cc
14D Specific cerebrovascular disorders except TIA with i/v thrombolytic without cc

In order to describe the technical changes we kindly ask the assistance of Nordic Casemix Center.

2014_1_24_DRGs 14ABCD_EST.xlsx - Appendix 1 (14.5 KB) Kristiina Kahur, 2015-01-24 12:24

ITT-grouping-1.jpg (169 KB) Martti Virtanen, 2015-02-24 12:45

ITT-grouping-2.jpg (80.1 KB) Martti Virtanen, 2015-02-24 12:45

368case.27.3.2015.jpg (23.3 KB) Anonymous, 2015-03-27 10:20

Case #368 Technical changes.xlsx - Updated 2015-04-17 (27.6 KB) Martti Virtanen, 2015-04-17 13:55

History

#1 Updated by Anonymous over 4 years ago

  • Priority changed from Major to Normal
  • Case type set to Major

#2 Updated by Anonymous over 4 years ago

  • Priority changed from Normal to Major
  • Target version set to Major-Proposals-for-2016

#3 Updated by Martti Virtanen over 4 years ago

  • File ITT-grouping.jpg added
  • Description updated (diff)

#4 Updated by Martti Virtanen over 4 years ago

  • Description updated (diff)

2015-02-18 Martti Virtanen
The problem here is that the basic coding is different in Estonia. The code AAL18 (not ALL18 as originally stated) or NCSP+ AACX18 'Intracranial endovascular arterial thrombolysis' Intravenous fibrinolytic therapy for acute ischemic stroke' only exist in Estonia. The other countries seem to be using AACX10 'Intracranial endovascular arterial thrombolysis' (AAL10 in most countries).
AACX18 has no properties whereas AACX10 is an OR=1 intervention with 5 other properties. The cases will usually be assigned to DRG 001C/A04N 'Intervention of intracranial vascular abnormality or infarction'. This DRG includes even surgical interventions has obvious a higher weight than the conservative DRG's 014A/B (A46E/C/A).
Estonia has also the code AAL10 with text 'Intrakraniaalne endovaskulaarne trombolüüs'. AAL18 has text 'Intravenous fibrinolytic therapy for acute ischemic stroke' (in English).
This seems to be mostly a mapping problem but one can ask, is it correct to combine the 'non-surgical' thrombolysis with 'surgical' therapy forms.

#5 Updated by Anonymous over 4 years ago

Mats Fernström, NPK, Sweden, 2015-02-24, Comment:
We don’t have any procedure code with the same meaning as AAL18 in Sweden so we cannot bring you any cost data for such cases and as we see it, the proposal is meant only for the Estonian version. But anyhow, we think that one should avoid to create a new group for only the cases with AAL18. The number of cases in the new group 14D would be small and the cost difference between the suggested new DRGs, 14C and 14D, only 15-16 % (Below the NordDRG limit for a DRG split - 20 % or more).

#6 Updated by Martti Virtanen over 4 years ago

  • File deleted (ITT-grouping.jpg)

#7 Updated by Martti Virtanen over 4 years ago

#8 Updated by Anonymous over 4 years ago

Mats Fernström, NPK, Sweden, 2015-03-05
First a comment to Marttis comment from 2015-02-18:
We must not mix up AAXC10 (AAL10) 'Intracranial endovascular arterial thrombolysis' and AACX18 (AAL18) 'Intravenous fibrinolytic therapy for acute ischemic stroke'. AAL10 means that a catheter is introduced in an intracranial artery (needs X-ray) and it was decided at the expert meeting last year (NCC case #229) that AAL10 shall be assigned to DRG 001C (A04N) 'Intervention of intracranial vascular abnormality or infarction'.
AAL18 is a much more simple procedure since the fibrinolysis is given via a peripheral vein. AAL10 and AAL18 should not be mapped together in NCSP+.
Second a correction of the text in my previous comment:
The text: “But anyhow, we think that one should avoid to create a new group for only the cases with AAL18” is wrong. The right text is: “But anyhow, we think that you should consider to create only one new group for the cases with AAL18 because the number of cases in the group 14D is rather small”.

#9 Updated by Martti Virtanen over 4 years ago

2015-03-13 Expert group/MV
It is unclear how intravenous thrombolytic therapy (of brain) is registered in the NordDRG countries.
Estonia has the specific code.
Finland and Iceland have a code PXXX22 'Intravenous arterial thrombolysis'.
All countries except Denmark have the code ZPXA00 'Thrombolytic agent' but it's use is limited to intraoperative situations.

It was agreed that the Estonian problem should be solved, but it seems probable that there is a hidden problem in other countries.

#10 Updated by Martti Virtanen over 4 years ago

  • File Case #368 Technical changes.xlsx added

2015-03-26 Martti Virtanen
My proposal for the change is that we create the two new DRG's as proposed by Estonia. Please check the Case #368 Technical changes.xlsx for details.
This demands a new property. If it given also to PXXX22 the new DRG's become available also in Fin and Den versions

#11 Updated by Anonymous over 4 years ago

SWEDEN/ Ralph Dahlgren

If we understand the technical changes correctly we can accept the new “ord” that is suggested except the following suggestions below:

#12 Updated by Kristiina Kahur over 4 years ago

2015-03-30 Kristiina Kahur

As I have not enough competency in assessing the technical changes what have to be done to make that suggestion operational I fully rely on Martti's and others' expertise.
However, the technical change which assigns the cases to DRG A46A is not what we expect.
I am confident there is opportunity to implement the rules which will make the desired changes in grouping logic possible.

#13 Updated by Martti Virtanen over 4 years ago

  • File Case #368 Technical changes.xlsx added

2015-03-31 Martti Virtanen
The change of the ord codes for the rules needed for making space for the new rules, is obviously not valid for NordDRG SWE. The ord code is actually not the same as in SWE version.

However the point is usefull! I have now modified the new rules so that they do not have the same ord values as the Swedish ones.
The IN statements are however more important tha the OUT statements. They are neithe valid for SWE and might have caused an error. They are now also marked not for SWE!

Technical changes is updated accordingly.

Finland and Iceland have to agree wether the change shall affect NordDRG FIN&ICE

#14 Updated by Martti Virtanen over 4 years ago

  • File deleted (Case #368 Technical changes.xlsx)

#15 Updated by Martti Virtanen over 4 years ago

2015-04-17 Martti Virtanen
There was an error in the technical changes ord-coding. It is now corrected.

#16 Updated by Martti Virtanen over 4 years ago

  • File deleted (Case #368 Technical changes.xlsx)

#17 Updated by Martti Virtanen over 4 years ago

2015-05-06 Martti Virtanen
Finland (and Iceland) have accepted the change also for code PXXX22 'Intravenous arterial thrombolysis'. If the change creates problems, it can be removed in production version.

#18 Updated by Martti Virtanen almost 4 years ago

2015-12-16 Martti Virtanen
The same model will be introduced also in Latvian version of NordDRG. This means that there will be also a Latvian specific version of NordDRG.
It will include the rules of Estonian version for this case

#19 Updated by Anonymous over 3 years ago

  • Target version changed from Major-Proposals-for-2016 to Expert Group 2015

#20 Updated by Martti Virtanen over 3 years ago

2016-03-15 Expert group (MV)
The changes were accepted without futher discussion

#21 Updated by Anonymous about 3 years ago

  • Status changed from Active to Accepted

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