Case #496

Case #370: Gender Validation

Reintroduction of DRG Z73 ‘Patient’s gender is missing’

Added by Mats Fernström almost 5 years ago. Updated almost 3 years ago.

Status:AcceptedStart date:2016-12-21
Priority:MajorSpent time:-
Assignee:Mats Fernström
Category:-
Target version:Expert Group 2017
Initiator:Sweden Target year:2018
MDC:GEN Owner / responsible:National organisations
Target Grouper:SWE Old forum status:

Description

Problem
In association with deletion of the gender validation (case #370), also the DRGs Z73 ‘Patientens kön fattas’ (Patient’s gender is missing) (DRGs 470G & 470V in Common version) were deleted which was a mistake. Grouping of an inpatient with a principal diagnosis belonging to MDC 98 will now result in DRG Z71N ‘Huvuddiagnos ogiltig’ (Invalid principal diagnosis) (DRG 470 and rtc 8 ‘Invalid principal diagnosis’ in Common version) if the patients gender is not registered and outpatients are grouped to DRG Z80O ‘Besökstyp el yrkeskategori saknas’ (Type of visit or type of professional is missing) although both the type of visit and the type of professional have been registered. Thus, the information to the NordDRG user is wrong. The correct information is that the patient’s gender is missing and therefor the DRGs Z73 ‘Patientens kön fattas’ (Patient’s gender is missing) must be reintroduced.
Decided changes
NPK, Sweden – 2016-12-21
Sweden has decided to reintroduce the DRGs Z73 ‘Patientens kön fattas’ in the Swedish version for 2018. The other nations should consider reintroducing the DRGs 470G & 470V.
DRG change
In the Swedish version, patients with a principal diagnosis belonging to MDC 98, but without information about the gender, will be grouped to DRG Z73 ‘Patientens kön fattas’ instead of DRG Z71N ‘Huvuddiagnos ogiltig’ or DRG Z80O ‘Besökstyp el yrkeskategori saknas’.
Technical change
Only changes in the Swedish version are described here.
In the table Drgnames: Insertion of DRG Z73R ‘Patientens kön fattas, primärvård’, DRG Z73O ‘Patientens kön fattas, besök’ and DRG Z73N ‘Patientens kön fattas’.
In the table Drglogic: Insertion of three new rules (one for primary care leading to DRG Z73R, one for specialized outpatient care leading to DRG Z73O and one for inpatient care leading to DRG Z73N). In each rule, “98” is inserted in the MDC field and a minus sign is inserted in the SEX field.
In the table Rtc: The value “2” with the text “Patientens kön fattas” is reinserted.
The changes are specified in the Excel file Decision C670.

Decision C670.xlsx (20.4 KB) Mats Fernström, 2016-12-21 13:49

Technical changes case #496.xlsx (19.5 KB) Martti Virtanen, 2017-05-08 15:29

Technical changes case #496 new.xlsx (24.6 KB) Martti Virtanen, 2017-09-14 14:31

TC_ #496_C670_SWE_new.xlsx (18.2 KB) Mats Fernström, 2017-10-05 13:50

Technical changes case #496 new-3.xlsx (76.4 KB) Martti Virtanen, 2017-10-08 05:18

TC_#496_C670_SWE_new_2.xlsx (19 KB) Mats Fernström, 2017-10-12 14:48

History

#2 Updated by Kristiina Kahur over 4 years ago

Finnish National DRG-centre 2017-3-5

We support the reintroduction of DRGs 470G and 470V.

#3 Updated by Kristin Dahlen over 4 years ago

Norway do not want the new 470 DRGs in our version. As we do have only one DRG 470, the rules might be introduced to this DRG if needed.

#4 Updated by Martti Virtanen over 4 years ago

2017-03-13 Expert group
Accepted as proposed

#5 Updated by Martti Virtanen over 4 years ago

2017-05-08 Martti Virtanen
The rules for missing gender of the patient are not only reintroduced, they become more strict than they were in NordDRG 2015. All cases with missing gender and MDC 98 principal dx will now result in an error message.
For versions with Swedish style DRG's for different errors the DRG's will be 470V/Z73O for outpatients and 470G/Z73N.
Primary care rules exist only in NordDRG Swe where the DRG is Z73R.
In countries with just DRG 470(X) the DRG will be 470. This achieved by mapping the above mentioned DRG's to 470 in the national DRGnames table. Z73R does not need any mapping since the rule exist only in NordDRG Swe.
The rtc-table is not actively maintained and it has not been changed. The rtc-values are the same as in NordDRG 2015.

Technical changes for combined NordDRG Com are attached. The DRGnames for national versions can be defined by national authorities. 470 with the existing name will be used, if not modified by the national authorities.

#6 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #496 new.xlsx added

2017-06-10 Martti Virtanen
There is a problem with this case. Current rules say, that the MDC is always converted from 98 to 13 if the patient is female and otherwise to 12. This did not matter as long as the gender was checked separately and had always to be either male or female if MDC is either 13 or 12.
With the new rule the MDC must stay 98 if sex is not male or female. The new rule is thus:
If dgkat is of type '98Mxx' it is changed to '13Mxx' if the patient is female and to '12Mxx' if the patient is male.

This creates two new problems:
1) The new rules take over from rules that do not demand MDC.
2) Patient cases with principal dx from the MDC 98 group and unclear gender cannot be assigned to neither MDC 12 nor MDC 13 DRG's

The first case is solved by moving the rule to postMDC area of the logic.

The second case is more problematic. It is about genital infections, sterilization and genital anomalies and injuries. Sterilization might be theoretical problem. Genital infections obviously occur also with unclear gender and genital anomalies actually cause unclear gender and may need care for interventions for gender specific organs.

I made the changes for fhe first case, but I leave the case further active for discussions about the second case.
The correctiosn are included in the new technical changes table.

#7 Updated by Mats Fernström over 4 years ago

Mats Fernström, NPK, Sweden 2017-06-14
I do not understand Martti´s comment “All cases with missing gender will now result in an error message”. The rules in Drglogic leading to DRG Z73/470 are valid only for cases with a principal diagnosis belonging to MDC 98.
Nevertheless, Martti is right about the need for a change of the rule in the grouper. With the present rule, cases with a dgkat of the type '98Mxx' will have a dgcat of the type '12Mxx', not only if the patient is male but also if information about gender is missing. (I thought that the rule already was written as Martti now suggests. This is another example of “black boxes” in the NordDRG system that should be avoided in the new NDMS.)
Martti is also right about the positions of the drglogic rules leading to DRG Z73/470. The most important disadvantage with the positions (ORD) that we originally suggested is that newborns with unclear gender will be grouped to DRG Z73/470 instead of a more meaningful group in MDC 15. Thus, we support that the rules are placed in the postMDC area of the logic.
The second problem mentioned by Martti (cases with really unclear gender that don’t belong to MDC 15) is probably not existing in Sweden. The legal gender, male or female, is always decided within some weeks after birth and it is the legal gender that is registered in our national patient register. If other countries allow uncertainty about gender for a longer period (like Germany) we could still have the rules leading to DRG Z73/470 but with another DRG code and the text “Urogenital problems when gender of patient is unclear or missing”.

#8 Updated by Ralph Dahlgren over 4 years ago

2017-06-15
Concerning this case Sweden want to discuss this case at at a meeting. The next bigger meeting is the Nordic Expert Group meeting in Stockholm 4-5 September. Before this discussion is done Sweden do not want any changes to be done to any grouper on the Swedish market.

#9 Updated by Martti Virtanen over 4 years ago

2017-06-16 Martti Virtanen
The Finnish classification of gender published in 1997 in the official register of health care classifications has 5 levels:
0 - unknown
1 - male
2 - female
3 - no information
9 - unspecified

I do not quite understand the differences between 0, 3 and 9 but anyway they open a possiblity to register an unclear gender at any age.
For the case of unclear gender of a newborn this allows registration without 'deciding' the gender as male or female. For the newborns this is indeed needed, because the decission on gender has longterm consequences for the child and it is not allways possible to decide correct gender at that age. This has been the tradition among paediaric endocrinologists and neonatologists already before the system really allowed it.

The rule change is necessary for the new rules to work at all. I agree with Mats that this is kind of a hidden rule. It is published on the old NordDRG Manual, but that is forgotten by everybody, including me. For example the new presentation of the rules collected by Norway states:

3.1.2 Recoding of specific DiagnosisCategory codes
DiagnosisCategory codes starting with ‘98’ are recoded based on gender information from the Case Data:
• If Case.Sex=1, the two first digits of the DiagnosisCategory code (‘98’) are replaced with ‘12’.
• If Case.Sex=2, the two first digits of the DiagnosisCategory code (‘98’) are replaced with ‘13’.
• If Case.Sex is none of the above, the DiagnosisCategory code remains unchanged.

This is as we are now all think and it is obvious that in current situation that is how it must be.

The other problem is the point I was trying to make earlier but forgetting to put 'with MDC 98' (I correted it now). The patient cases have previously been possible to assign to DRG's that do not demand any specified MDC.
This can be corrected by positioning of the new rules to postMDC area. It allows the rules without specified MDC to function normally with the MDC 98 principal dx's.

The problem of MDC 98 dx's without specified gender (cas 2 in my previous comment, now better formulated) is more problematic. That certainly need consideration. We might need to combine existing DRG's that are gender dependent?

To the Swedish comment on introduction. This case can be totally postponed and now changes made. The effect is the same if the rule changes are not accpted. I presume that all groupers except the Norwegian work in the old way. As we anyway agree that the new way is the correct one, I propose that we accpt the change. The order change is less essential but as it does not affect anything else than this minor detail and as it is logical I would recommend to take it.

#10 Updated by Kristiina Kahur over 4 years ago

Finnish National DRG-centre 2017-6-15

We support Martti's proposal in current case. However, it doesn't rule out any further discussion we may need to go through.

#11 Updated by Mats Fernström over 4 years ago

Mats Fernström, NPK, Sweden 2017-06-15
We have already accepted positioning of the new rules to the postMDC area. Ralphs comment was just about changes in the grouper. However, it is now clear that not only the Norwegian grouper handles DGCAT 98Mxx as intended. Also the SOS grouper and Örjans grouper (DRG Systems) have the right rules. And I tested Datawells Web-grouper and it seems as it also works as we want. I tested with a case with DGCAT 98M03 and omitted the gender. It did not result in DRG N50 (Inflammation i genitalia hos man) which should have been the result if the grouper had converted 98M03 to 12M03. Maybe the wrong rule for handling DGCAT 98Mxx is present only in the FoxPro grouper???

#12 Updated by Ralph Dahlgren over 4 years ago

2017-07-20
The Exell-file with the name ” Technical changes case #496 new.xlsx (20,258 KB) Martti Virtanen, 2017-06-10 09:21” contains a sheet called “ “Rule”.
This sheet has “OUT” and “IN”. It was produced before Marttis last comment on Forum 2017-06-16.
The content of the sheet “Rule” is not correct and should either be re-moved/erased or modified to correspond to the text that Martti has written 2017-06-16.
Technical Changes should be as correct as possible on Forum and this sheet is not correct/complete.

#13 Updated by Martti Virtanen about 4 years ago

  • File Technical changes case #496 new.xlsx added

2017-09-04 Expert group
The expert group discussed the question Sweden has brought up. There was dispute wether a rule that does not change anything is a rule. However, to make the matter clear we have now modified the new rule text in the technical changes:
If dgkat is of type '98Mxx' it is changed to '13Mxx' if the patient is female and to '12Mxx' if the patient is male.(If patient has neither male nor female gender registered, the dgkat remains unchanged)

#14 Updated by Martti Virtanen about 4 years ago

  • File deleted (Technical changes case #496 new.xlsx)

#15 Updated by Martti Virtanen about 4 years ago

  • File Technical changes case #496 new.xlsx added

2017-09-06 Martti Virtanen
The logic for missing gender needs a further correction. The variable sex in the Drglogic tables has had values:
'M' = male
'F' = female
'-' = unknown or unclear
' ' = not in use
Correspondingly the input (patient) data must have values:
'M'/'1' = male
'F'/'2' = female
'-' = unknown or unclear

This demands conversion of the original patient data especially in the case of unknown or unclear gender. This was necessary because there were specific rules for cases with unknown or unclear gender in NordDRG 2015 (and before) that were active for dx belonging to MDC 12, MDC 13 and MDC 14 in addition to dx belonging to MDC 98.

As pointed out by FCG-prodacapo team, the content of the sex-variables is not logical. '-' means logically not male nor female and ' ' means unknown.

The new rules at issue all demand MDC='98'. That value occurs within the grouper only when neither male or female gender is registered. Gender is only needed when the dx demands additional information on gender (for dx's belonging to dgkat 98Mxx) for conversion to MDC = 12 or MDC 13 diagnosis categories. (There is now conversion to MDC 14.)

Therefore there is no reason to demand 'not female nor male' (sex='-') in the rules with MDC='98'. In practice sex = '-' of the logic can and must be taken out.

After all corrections the variable sex will (again) not be used at all in the logic. The rules proposed by Sweden are necessary but without sex='-'.

I have now corrected the technical changes accorgingly.

#16 Updated by Martti Virtanen about 4 years ago

  • File deleted (Technical changes case #496 new.xlsx)

#17 Updated by Martti Virtanen about 4 years ago

2017-09-14 Martti Virtanen
Another problem with the case.
Patient cases without gender and with MDC98 dx are assinged to Z80R 'Swe - Besökstyp el yrkeskategori saknas, primärvård' instead of Z83R that was expected. This is because ther rule for Z80R is earlier (ord #00D003410) than that for Z73R (ord #00D900000).

To correct this the rule for Z80R has to be moved below Z83R (ord #00D900100). As can be seen in the new technical changes the groups between are not affected because they all have los >0.

#18 Updated by Martti Virtanen about 4 years ago

  • File deleted (Technical changes case #496 new.xlsx)

#19 Updated by Mats Fernström about 4 years ago

Mats Fernström, NPK, Sweden 2017-10-05
We have grouped the Swedish patient register both with and without the minus sign in the "sex" field in the Drglogic table and received the same grouping results. The minus sign, therefore, does not matter to the grouping and we accept that it is removed.
We also tested the effect of transferring the DRG Z73 rules from the preMDC area to the postMDC area and found that a significant number of cases received more information-bearing DRGs instead of DRG Z73. In these cases, the procedure codes decided the grouping and it did not matter that gender data was missing. It is therefore good that the rules have been moved to the postMDC area.
However, in this test, we found that 111 cases in outpatient care were grouped to DRG Z60O ‘Non-extensive o. r. procedure unrelated to principal diagnosis, short therapy' (former DRG 477O) and 12 cases in hospital care were grouped to DRG Z50A/C/E 'Extensive o. r. procedure unrelated to principal diagnosis' (former DRG 468). However, 105 of the 111 cases in outpatient care and all 12 inpatients had a procedure code with a procedure property starting with 12 or 13, so if it there had been a gender information, they would possibly have been grouped to a more informative and procedure related DRG. In these cases, DRG Z73 ‘Information about gender is missing' would have been more correct than the DRGs Z50/Z60 and it would give the NordDRG user better information and a chance to correct the registration.
To achieve this improvement, we want the DRG Z73 rules to be moved once more and then to a place just before the DRGs Z50/Z60. This is described in "TC_#496_C670_SWE_new.xlsx".

#20 Updated by Martti Virtanen about 4 years ago

2017-10-05 Martti Virtanen
The matter is not quite clear yet.
The proposal from Sweden by Mats Fernström about the relationship to 477/Z50 and Z60 has 3 main areas that should be looked at separately. The changes and problems can be most clearly seen in the new version of technical changes for this case.

Inpatients (green background for column IN/OUT)
For inpatient the proposed new position of the rule is the same that I have proposed, the slight difference in the ord-code value has no effect on DRG assignmet.

Outpatients (orange background for column IN/OUT)
For outpatient grouping the rule cannot be placed in the proposed new position because it will affect other versions in an unwanted way.
To avoid this the Nor (DRG 980X and 981X) and Ice (DRG 998O) rules together with the common DRG 477O rule have to be moved to just before the Swedish 477O (Z60O) rules and after the new DRG 470V (Z73O) rule. The rules between are only specific SWE-version rules. Therefore the change will not affect other versions but avoid possible effects on SWE-version.

Primary care (blue background for column IN/OUT)
For the SWE-version primary care DRG’s the proposed original position of DRG Z73R means that unclear gender takes precedence over a large number of primary care groups that are not dependent on MDC nor gender (all rows with violet background for columns after IN/OUT).
If the rule for DRG Z73R is placed as proposed, the cases with MDC 98 principal dx and unspecified gender will not be considered for these DRG’s as they are assigned to DRG Z73R. This should be avoided.

To this group belong also the following rules (with green background for columns after IN/OUT)
Z50R ‘Swe - Tyngre sällsynt, eller felaktig, kombination av huvuddiagnos och åtgärd, primärvård’
Z60L ’Swe - Annan sällsynt, eller felaktig, kombination av huvuddiagnos och åtgärd slutenvård, primärvård’
Z60R ‘Swe - Annan sällsynt, eller felaktig, kombination av huvuddiagnos och åtgärd, primärvård’
Z80L ‘Swe - Besökstyp el yrkeskategori saknas slutenvård, primärvård’
Z80R ‘Swe - Besökstyp el yrkeskategori saknas, primärvård’
X69L ‘Swe - Slutenvård för annan vård, primärvård’

All these DRG’s are residual groups where, if the gender would have been correctly coded, the cases would not have been assigned to these DRG’s. Thus it is preferable to report Z73R - unclear gender as DRG.

To reach these goals the rule for Z73R must be placed immediately before the rule for Z60R (before #00D003400). The problem with Z50R that must be solved by a adding immediately before its rule a rule (ord #00D000209) assigning this type of cases with MDC 98 to DRG Z73R

#21 Updated by Mats Fernström about 4 years ago

Mats Fernström, NPK, Sweden 2017-10-12
I have read Technical changes case #496 new-3.xlsx added by Martti 2017-10-08 and have the following comments:
The rule with ORD #00D000209
The rule leads to DRG Z50R ’Tyngre sällsynt, eller felaktig, kombination av huvuddiagnos och åtgärd, primärvård’ which probably is a mistake according to his comment 2017-10-05 where he says: “a rule (ord #00D000209) assigning this type of cases with MDC 98 to DRG Z73R”. Nevertheless, we do not need this rule since it is based on PROCPRO 99S90 ‘Extensive procedure’ and this type of procedures do not occur in primary care. We will not include this rule in the SOS version.
The rule with ORD #00D003398
This is exactly the same as our rule with ORD #00D003399 and the slight change of the ORD value does not move the rule to another position than what we want. Thus we accept Marttis ORD.
The rule with ORD 278D990000
This is exactly the same as our rule with ORD 270D999999 and the change of the ORD value does not move the rule to another position than what we want. Thus we accept Marttis ORD.
The rule with ORD 499D001800
This ORD is the same as what we already have in the SOS version but as we said in our previous comment, we want to move it five rows up to a place just before the rule for DRG Z50A with ORD 499D0001001 and then the ORD 499D0001000 seems adequate.
The ORD changes described above are inserted in the included file TC#496_C670_SWE_new_2.xlsx_.

#22 Updated by Martti Virtanen almost 4 years ago

  • Status changed from Active to Further active

2017-01-09 Martti Virtanen
Just to give everybody an opportunity to view this extremely complex process, I leave this as active.
I still think, we should combine the MDC's 12 and 13 to be able to remove all gender dependent rules!

#23 Updated by Martti Virtanen almost 3 years ago

  • Status changed from Further active to Accepted

2018-03-13 Expert group
The expert group confirmed the changes.
Case is closed.

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