Case #470

Malignant melanoma of eyelid

Added by Kristin Dahlen over 4 years ago. Updated over 2 years ago.

Status:AcceptedStart date:2016-02-25
Priority:MinorSpent time:-
Assignee:-
Category:-
Target version:Expert Group 2016
Initiator:Norway Target year:2017
Case type:Minor Owner / responsible:
MDC:MDC02 Old forum status:
Target Grouper:COMMON

Description

Subject: Malignant melanoma of eyelid

Description: Change of property for C431 Malignant melanoma of eyelid from DGCAT 02M99 to 09M03

National ID: HD-0153
Initiated: 2016-02-19
Initiator: The Norwegian Directorate of Health

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Problem

Malignant melanoma of eyelid do currently have DGCAT 02M99. This leads to problems when it comes to the Norwegian DRG-solution for cancer drug treatment. Most of the MDC do have their own DRG covering drug treatment for cancer. For those MDC’s who do not have a specific DRG, a DRG 856X Outpatient cancer drug treatment for other cancers.

DRG 856J Outpatient cancer drug treatment for malignant melanoma shall cover all cases with malignant melanoma. Malignant melanoma of eyelid do, however, have a DGCAT 02M99. This leads cases to DRG 856X for other cancers. This does not seem reasonable.

Suggestion
The Norwegian Directorate of Health – 2016-02-19

We suggest that C431 changes DGCAT from 02M99 to 09M03.

Decisions Helsedir HD-153 Malignant melanoma of eyelid.xlsx (13 KB) Kristin Dahlen, 2016-02-25 13:32

maligntmelanom.jpg (69 KB) Kristin Dahlen, 2016-02-25 13:40

maligntmelanom.jpg (55.5 KB) Martti Virtanen, 2016-03-27 15:51

maligntmelanom.jpg (467 KB) Martti Virtanen, 2016-03-27 15:53

maligntmelanom.jpg (181 KB) Martti Virtanen, 2016-03-27 15:56

Case 470_FORUM_Malignant melanoma of eyelid_national change_norsk tillegg.xlsx (167 KB) Kristin Dahlen, 2016-04-13 15:13

Technical changes case #470.xlsx (126 KB) Martti Virtanen, 2016-05-24 15:25

Appendix #470 SWE 2017.xlsx (14.8 KB) Mats Fernström, 2017-03-08 17:09

Technical changes case #470 add.xlsx (119 KB) Martti Virtanen, 2017-05-29 11:05

History

#1 Updated by Kristin Dahlen over 4 years ago

  • Target version set to Expert Group 2016

#2 Updated by Kristin Dahlen over 4 years ago

#3 Updated by Anonymous over 4 years ago

  • Description updated (diff)

#4 Updated by Kristiina Kahur over 4 years ago

Finnish National DRG-Centre 2016-2-29

Should the suggestion concern also e.g. diagnosis codes D031 (Melanoma in situ of eyelid, including canthus) and D221 (Naevus melanocyticus palpebrae)?
Currently, for instance, diagnosis codes D032 (Melanoma in situ of ear and external auricular canal) or D222 (Naevus melanocyticus (cutis) auriculae) have the DGCAT 09M99 (Minor skin disorders) and not the one according to anatomy. Same with some other diagnosis codes with have the DGCAT 09M99 instead of MDC linked to anatomical area. That would make the logic behind given DGCATs consistent.

#5 Updated by Mats Fernström over 4 years ago

Mats Fernström, NPK, Sweden, 2016-03-02
Sweden cannot accept this suggestion. The change of the DGCAT from 02M99 to 09M03 is an extremely powerful change, especially since it means a change of MDC. It will affect not only the Norwegian DRGs for cancer drug treatment but also the grouping of all other cases with malignant melanoma of eyelid, also the cases with surgery, inpatients as well as outpatients, in all national versions and that effect is not analyzed. It is possible that MDC 09 is better also for the cases with surgery but we don’t know. We can make a proper analysis later this year (for decision at the spring meeting 2017) if it is wanted.
Otherwise, we think that Norway can solve the problem with the DRGs for cancer drug treatment by giving C431 (and possibly other codes suggested by Finland) a new PDGPRO (e.g. 09P05 ‘Skin tumor on eyelid’) and by construction of a new rule for DRG 856J based on that PDGPRO instead of MDC 09, in addition to the present rules for DRG 856J. This can be done in the Norwegian version for 2017 (ORD value 100D800037 is not occupied) without any effects on the other versions.
(By the way, looking at the Norwegian Drglogic table, I don’t understand why DGPROP 90X02 ‘Benign tumour’ is involved in the rules for the DRGs beginning with 856.)

#6 Updated by Martti Virtanen over 4 years ago

2016-03-09 Nordcase - Martti Virtanen
I agree with Mats Fernström in this matter. I suspect taht the operative cases are more eye than skin related and should stay in eye grouping. The proposal of using Principal diangosis property with a new rule is attractive.

#7 Updated by Kristin Dahlen over 4 years ago

Norwegian Directorate of Health 2016.03.11

Melanoma of the eyelid is a very rare disease; however it is a skin disease. The treatment of melanoma of the eyelid is different from the treatment for melanoma with most other locations. Melanoma in the eyelid should be treated by oculoplastic surgeons and specialized care must be taken because of the location and the eyelids special structur and important function. Melanoma of the eyelid is comparable to melanoma of the ear do to special care which must be taken and because of the delicate structur and thin skin. Therefore it seems not right that melanoma of the eyelid should have another MDC than for other melanomas in the skin including melanoma of the ear.
Only a couple of cases (five cases during the last 8 months in 2015 in Norway) concern surgical treatment for melanoma of the eyelid.
On this background we argue that the change in MDC group for melanoma of the eyelid can be done from 2017.

#11 Updated by Martti Virtanen over 4 years ago

2016-03-15 Expert group (MV)
The case was postponed for further analysis by SWE and FIN
If necessary special arrangements can be concidered for Norway.

#12 Updated by Kristin Dahlen over 4 years ago

Minor update - Norwegian change

Norway want to do a minor change in the national version regarding cancer drug treatment in DRG 856J and malignant melanoma of eyelid. DRG 856J Outpatient cancer drug treatment for malignant melanoma shall cover all cases with malignant melanoma. As our suggestion of changing DGCAT for C43.1 Malignant melanoma of eyelid required further analysis from other countries, we will do a minor change only affecting the Norwegian version.
The Norwegian change will be to create a new rule for DRG 856J based on PDGPRO 09P01 ‘tumor of skin’. This rule can then replace the rules already existing for DRG 865J.

We still want to keep the case open for next year to consider the more common change

#13 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #470.xls added

2016-05-24 Martti Virtanen
The proposed change deals with all skin tumors not just melanomas. The existing groups have the same error. Properties 09X01, 09X02 and 09P01 include all skin tumors including the benign tumors of skin.
Cytostatic treatment is hardly given to benign tumors and even for basal cell carcinoma and squamous cell carcinoma this is rare. Kaposi cell sarcoma that is also included may be different.
Thus at least the name of the groups are wrong - this is about skin tumors in general not about melanoma.

If grouping of only melanoma is the goal, we need a new principal dx property to indicate melanoma and base the grouping on that property.
In the technical changes document the C4310 is marked with yellow in the ICD+ sheet. The other malignant melanomas are indicated with green. The melanoma in situ codes (that also have 09P01) are indicated with blue (the table is filtered to show the Norwegian codes, other codes are included). It is questionable whether the last group should be included.
Since the change will only affect Norway we are prepared to do it. The errors are the same as in the previous version.
However, I hope Norway will consider the matter - if the intention is to create special groups for melanoma, we should change the rule, otherwise we should change the name of the DRG.

#14 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #470.xls)

#15 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #470.xls added

#16 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #470.xls)

#18 Updated by Mats Fernström over 3 years ago

Mats Fernström, NPK, Sweden 2017-03-08 (NPK ID C637)
That the diagnosis codes for melanoma of the eyelid are grouped to MDC 02 is something that we have inherited from the American HCFA DRG. Norway suggests that the codes are transferred from MDC 02 (eye diseases) to MDC 09 (skin diseases) on the grounds that it is actually a skin disease. We have analyzed such a change.
Analysis
The Swedish national patient register (PAR) for 2015 was grouped with NordDRG SWE 2017. The resulting DRG was called DRG1 in our analysis. Then the definition table DG1 was changed according to the sheet “Technical changes” in the file Appendix #470 SWE 2017.xlsx. Thus, MDC was changed from 02 to 09, DGCAT was changed from 02M99 to 09M03 and DGPROP from 02X99 to 09X99 for the Swedish ICD codes for melanoma of the eyelid. Then PAR was regrouped and the new DRG was called DRG2. The comparison, DRG1 vs DRG2 is shown in the sheet “Results PAR aggregated”. There were just 3 inpatients and 67 outpatients where DRG2 differed from DRG1. The majority, 60 cases, went from DRG B99O (Other eye disorders, short therapy) to either DRG J45O (Major skin disorders, short therapy) or DRG J99O (Other skin & subcutaneous tissue disorders, short therapy). As seen in the appendix, the average costs for DRG1 and DRG2 are very similar and the percentage of cases changing DRG is very, very low.
Summary
The effect of the suggestion is almost negligible and we do not have any strong opinion. What possibly speaks for the proposal is that most of the patients in our analysis were not treated in an eye clinic (see sheet “Clinics”) but that is not important either. If Norway believes that the proposal is important, we can support it for the sake of good neighborly relations.

#19 Updated by Kristiina Kahur over 3 years ago

Finnish National DRG-centre 2017-3-8

Currently we do not have the tool to simulate the analysis done by Sweden, thus we cannot present “DRG2” results as indicated in Mats’ analysis. However, we did our best to see how the cases under discussion are currently grouped. We also checked the cost data and estimated the results of regrouping.
In Finland dx code C431 has several sub-codes (C43.11-14, C43.19) depending on histology of the tumor.

In 2015, there were 126 cases with main dx C43.xx.
- Ca 50 % (# 78) were grouped to DRG 902O, mean cost 166 EUR. The cases have no procedures and consist mainly of doc’s appointment.
After the suggested change those cases would likely group to DRG 909O, mean cost 186 EUR which is close to mean cost of 902O.
- Ca 20 % (# 28) were grouped to DRG 917U or 917V (Malignancy of eye, radiotherapy, short therapy), mean cost 123 EUR.
After the change those cases would likely group to DRG 909A (Malignancy of skin, radiotherapy, short therapy), mean cost 164 EUR which is close to mean cost of 917U and 917V.
- The rest of the cases (# 20) are grouped to nine different DRGs (in- and outpatient), the mean cost of single DRGs varies between 482-12 803 EUR.
After the suggested change the cases would likely group to different MDC9 DRGs as indicated in Swedish analysis. Given the small number of cases, the impact of regrouping of those cases from MDC2 to MDC9 DRGs should have minor impact.

In summary, based on the Finnish data we do not see big risk if the suggested change will be done. And seems that Swedish data do not oppose the change either.
As for relations with neighbors, we can discuss it during the meeting.

#20 Updated by Martti Virtanen over 3 years ago

  • File Technical changes case #470 add.xlsx added

2017-03-13 Expert group
Accepted as proposed.
Analysis from Finland and Sweden indicate that MDC 09 is better than MDC 02.
Technical changes 495 add are included. The previous technical changes are still valid and help the correct DRG assignment of for example codes in the C44 group.
All cases with 'Malignangt melanoma of eyelid get assigned to skin DRG's in all NordDRG 2018 versions.

#21 Updated by Ralph Dahlgren over 3 years ago

20170521 Ralph DAhlgren:
When going through the technical Changes from Martti and compåaring them to the Swedish I noticed two differences.
The first is that in Marttis the code C431X Ospecificerat malignt melanom på ögonlock inklusive ögonvrå is not there. I Think this is due to the way Fox-Pro works and the Changes will be don to this code aswell due to mapping.
The other difference is something that I cannot understand.
The code D031 Melanom in situ på ögonlock inklusive ögonvrå is not in the technical Changes at all as far as I can see. This code should also be included, maybe it is also done due to mapping in ICD+ in Fox-Pro but otherwise please correct and change from MDC 02 to MDC 09, include all the grouping properties aswell naturally.

#22 Updated by Martti Virtanen over 3 years ago

2017-05-29 Martti Virtanen
Raplph has right, the change of D031 is missing in the technical changes.
I have now added it to the Technical changes

#23 Updated by Martti Virtanen over 3 years ago

  • File deleted (Technical changes case #470 add.xlsx)

#24 Updated by Martti Virtanen over 2 years ago

  • Status changed from Active to Accepted

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