Case #396

Task #11: Delivery of minor update proposals for NordDRG 2015

Case #245: Errors in the exclusion list 18C90 “Other severe infection”

Influenzas, pneumonias and other severe infections - CC/MCC categories and their exclusions

Added by Anonymous almost 5 years ago. Updated over 3 years ago.

Status:AcceptedStart date:2015-02-11
Priority:MinorSpent time:-
Assignee:Mats Fernström
Category:-
Target version:Expert Group 2015
Initiator:Sweden Target year:2016
Case type:Minor Owner / responsible:National organisations
MDC:GEN Old forum status:
Target Grouper:SWE

Description

Errors in the exclusion list 18C90 “Other severe infection”
Forum ID: Case #245
NPK ID: C529
Status: ACTITEM - Active item
Sent to NCC: 2015-02-05
----------------------------------------------------------------------------------------------------------------
Comments
Mats Fernström, NPK Sweden 2014-12-04
J101 ‘Influensa med andra respiratoriska manifestationer, annat identifierat influensavirus’(in ICD+ J1010 ‘Influenza with other respiratory manifestations, influenza virus identified’) is still on the exclusion list under 18C90 and 18G90 in NordDRG SWE 2015.

We guess that the reason is that J101 happens to have COMPL 18G90 and that the code then is automatically added to the exclusion list under 18C90 and 18G90 in NCC’s NDMS.
In the construction of the Swedish CC grouper it was decided that J101 shall have Major CC but the value 18G90 was probably a mistake. We think that 04G01 is better and J101 is already included in the exclusion list under 04C01/04G01.

When we looked at the properties of J101 we found that J111 ‘Influensa med andra manifestationer i luftvägarna, virus ej identifierat (in ICD+ J1110 ‘Influenza with other respiratory manifestations, virus not identified’) has no COMPL value at all and that seems very inconsistent. The only difference between J101 and J111 is whether the virus is identified or not. Thus, J111 also should have COMPL 04G01. J111 is already included in the exclusion list under 04C01/04G01.

Suggestion:

Technical changes:
• In the DG1 table, the COMPL value for J101 is changed from 18G90 to 04G01.
• In the DG1 table, the COMPL value 04G01 is added to J111.
• In the COMPLEX table J101 then can be deleted from the exclusion list of 18C90
Are described in detail in Appendix_Comment_Case245.xls.

DRG change:
Probably minor.
• Cases with J101 as principal diagnosis and any of the diagnoses with 18C90 or 18G90 as secondary diagnosis will be grouped to a CC or Major CC DRG instead of a non CC group.
• Cases with J111 as secondary diagnosis will be grouped to a CC or Major CC group instead of a non CC group (like cases with J101 as secondary diagnosis) if the principal diagnosis isn’t on the exclusion list under 04C01/04G01.

COMMENTS_on_NCC case 245.docx (15.9 KB) Anonymous, 2015-02-11 13:04

Appendix_Comment_Case245.xls (49 KB) Anonymous, 2015-02-11 13:04

Appendix_Comment_Case_396.xlsx (17.7 KB) Mats Fernström, 2016-01-27 15:58

Suggestion_#396.xlsx (17.7 KB) Mats Fernström, 2016-01-27 15:58

Technical changes case #396.xls (59.5 KB) Martti Virtanen, 2016-04-14 12:40

History

#1 Updated by Martti Virtanen over 4 years ago

  • Description updated (diff)

2015-02-23 Martti Virtanen
The reason why J010 belongs to the exclusion list of 18C90 is that all dx must be on exclusion list of complication category they belong to. Otherwise repeating the same code would result in CC/MCC grouping.

I agree that J1010 and J1110 should have the same properties at least in this respect. I recall that I wondered this, but the data did not support adding the complication category to J1110. It would of course be possible that J1110 would belong to 18C90 on CC level instead of MCC level (18G90).

The other question about 04C01/18C90 is more complex.

Currently pneumonias (J12-J19) may complicated by J1010 (but not J1110) but not by J1000 (Influenza pneumonia). On the other hand viral bronchitises may be complicated by both J1000 and J1010 as well as by the pneumonias. Pneumonias will not complicate influenza with respiratory manifestations since J1000, J1010, J1100 and J1110 are all on the exclusion list of 04C01. Pneumonias may complicate influenza without respiratory manifestations since J1080 and J1180 are not on the exclusion list. Then of course, the basic DRG is totally different.

The new model would mean that pneumonias would not be complicated by influenza. Influenzas except for non respiratory cases would neither be complicated by pneumonias.

Further analysis
First question is, does a bacterial (secondary pneumonia) complicate influenza? I.e. is it correct that Influenzas are on the exclusion list of 04C01? This is a question opposite to the presented one!
Second question is does influeza complicate a patient with other (bacterial)pneumonia? i.e. should the influenzas belong to the same complication category as pneumonias.
Third question is should infuenza complicate tropical and other rare infections (belonging to 18C90).

I think clinical answere is obvious but do these situations affect the resource use? This should in principle be analyzed for the decission with cost data if such exists. It would also be important to know, what are the actual problematic cases that initiated this discussion.

#2 Updated by Martti Virtanen over 4 years ago

  • Subject changed from Errors in the exclusion list 18C90 “Other severe infection” case 396 to Influenzas, pneumonias and other severe infections - CC/MCC categories their exclusions

#3 Updated by Martti Virtanen over 4 years ago

  • Subject changed from Influenzas, pneumonias and other severe infections - CC/MCC categories their exclusions to Influenzas, pneumonias and other severe infections - CC/MCC categories and their exclusions

#4 Updated by Ralph Dahlgren over 4 years ago

Sweden suggests that what was decided in #245 cases last year should be implemented. It is about this the case 396 is about from the beginning.
Martti's comments are a adequate problem but should be investigated for the version 0f 2017.

#5 Updated by Martti Virtanen over 4 years ago

2015-03-13 Expert group/MV
The case become too complicated to be solved now. It was postponed for further analysis. Sweden promished to perform economical analysis about the additional features.

#6 Updated by Martti Virtanen over 4 years ago

  • Status changed from Active to Further active

#7 Updated by Mats Fernström almost 4 years ago

Mats Fernström, NPK, Sweden 2016-01-20
The original reason for this case was that we questioned the compl.cat. 18G90 (Other severe infection- major CC) for the diagnosis J101 ‘Influensa med andra respiratoriska manifestationer, annat identifierat influensavirushas’. It was decided in the Swedish CC project some years ago that J101 should have MCC property but we think that the value 18G90 was a mistake, because then it is impossible that the other more severe diseases with 18G90 or 18C90 can complicate cases with the influenza diagnosis J101. We also found it very illogical that J111 ‘Influensa med andra manifestationer i luftvägarna, virus ej identifierat’ has no CC property at all. The only difference between J101 and J111 is whether the virus is identified or not.
Martti has added three questions to this case:
1. Does bacterial pneumonia complicate influenza?
2. Does influenza complicate bacterial pneumonia?
3. Does influenza complicate tropical and other rare infections belonging to 18C/G90?
We have tried to find the answers in the Swedish cost database (KPP) for 2014 grouped with NordDRG 2016.
For the first question we looked for cases with pneumonia (see table 1A) as the secondary diagnosis in the possible DRGs for influenza (see table 1B).
Table 1A
J139 Pneumoni orsakad av Streptococcus pneumoniae
J149 Pneumoni orsakad av Haemophilus influenzae
J150 Pneumoni orsakad av Klebsiella pneumoniae
J151 Pneumoni orsakad av Pseudomonas
J152 Pneumoni orsakad av stafylokocker
J153 Pneumoni orsakad av streptokocker grupp B
J154 Pneumoni orsakad av andra streptokocker
J155 Pneumoni orsakad av Escherichia coli
J156 Pneumoni orsakad av andra gramnegativa bakterier
J157 Pneumoni orsakad av Mycoplasma pneumoniae
J158 Annan specificerad bakteriell pneumoni
J159 Bakteriell pneumoni, ospecificerad
J160 Klamydiapneumoni
J168 Pneumoni orsakad av andra specificerade infektiösa organismer
J170 Pneumoni vid bakteriella sjukdomar som klassificeras annorstädes
Table 1B
DRG C35 (former DRG 070) Infektioner i övre luftvägar och öron
DRG S40 (former DRG 421) Virusinfektioner
We found only 58 cases with secondary pneumonia in the influenza DRGs. All but one were found in the complicated subgroups and the costs corresponded quite well to the average costs in these subgroups (see Appendix_Comment_Case_396.xlsx, sheet “Question 1”). This finding indicates that bacterial pneumonia can complicate influenza.
For the second question we looked for cases with influenza (see table 2A) as the secondary diagnosis in the possible DRGs for pneumonia (see table 2B).
Table 2A
J099 Influensa orsakad av vissa identifierade influensavirus
J101 Influensa med andra respiratoriska manifestationer, annat identifierat influensavirus
J108 Influensa med andra manifestationer, annat identifierat influensavirus
J111 Influensa med andra manifestationer i luftvägarna, virus ej identifierat
J118 Influensa med andra manifestationer, virus ej identifierat
Table 2B
DRG D31 (former DRG 080) Infektioner & inflammationer i andningsorganen, >17 år
DRG D32 (former DRG 081) Infektioner & inflammationer i andningsorganen, 0-17 år
DRG D47 (former DRG 091) Lunginflammation
We found 62 cases with influenza in the pneumonia DRGs (see Appendix_Comment_Case_396.xlsx, sheet “Question 2”). Most of them were grouped to complicated or very complicated subgroups although only J101 has CC property. This means that there must be another secondary diagnosis with CC or MCC property that may increase the costs but this is also the case in the comparison groups so therefore we think that we can include the complicated or very complicated subgroups in the analysis, otherwise there are only 14 cases in DRG D47E left in the study. We consider that the findings indicate that influenza can complicate bacterial pneumonia. This analysis is not large enough to answer the question if influenza without respiratory manifestations (J099, J108 & J118) also should have CC or MCC property. That has to be decided in a separate study including all existing diagnoses.
For the third question we did not look for any cases in the cost database. The infections belonging to 18C/G90 are very rare and combinations with influenza must be extremely rare so we considered it meaningless to search for them.
Since the number of observations in this study was rather low we consulted two specialists in infectious diseases (Olafr Steinum & Mats Karlsson) and asked for their opinions. Both of them consider that bacterial pneumonia certainly complicate influenza but they are hesitant to the opposite.
Suggestion summary
  1. As a matter of principle we think that the influenza diagnosis J101 must have another compl.cat. than the tropical and other rare infections belonging to 18C/G90 even though combinations with influenza are extremely rare.
  2. Also as a matter of principle the influenza diagnosis J111 must have the same compl.cat. as J101.
  3. Cost data, even though the number of observations in this study was rather low, indicate that bacterial pneumonia can complicate influenza and vice versa. Thus pneumonia and influenza must have different compl.cat.
    To achieve this we suggest a new compl.cat, 18G25 ‘Influenza- major CC’, that is given to the codes J101 and J111. For congruence, the compl.cat, 18C25 ‘Influenza’ is also created. The complication exclusion list must then be updated with exclusions for these new complication categories and J101 can be deleted from the exclusion list under 18G90. See “Suggestion_#396.xlsx” for details.

#8 Updated by Anonymous almost 4 years ago

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

#9 Updated by Martti Virtanen over 3 years ago

2016-03-15 Expert group (MV)
The case was discussed and accepted as modified by SWE

In producing the technical changes I had to do a few technical corrections

1) There will be only one new complication category 18C25 (with levels 18C25 and 18G25).
2) The affected codes are listed in ICD+ sheet
3) Exclusions are listed only for 18C25. For the Swedish version the 18G25 exclusion will be automatically added.

I addition there is one change that is principal. J1000 and J1100 'Influenza with pneumonia...' cannot be comblicated as principal dx by repeating the same information wit J1010 and J1110 'Influenza with other respiratory manifestations...' as secondary dx. Therefore J1000 and J1100 must be exclusions of 18C25.

#10 Updated by Mats Fernström over 3 years ago

Mats Fernström, NPK, Sweden 2016-04-14
We do not have all the automatics that are available in FoxPro-NDMS so to be able to construct our own definition tables we have to specify properties that are automatically generated in FoxPro-NDMS. We agree that J100 and J110 must be on the exclusions of 18C25.

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