Case #503

DRG 315 Other kidney and urinary tract o. r. procedures– splitting into different groups

Added by Kristiina Kahur over 3 years ago. Updated over 1 year ago.

Status:AcceptedStart date:2017-01-16
Priority:MajorSpent time:-
Assignee:Kristiina Kahur
Category:-
Target version:Expert Group 2017
Initiator:Finland Target year:2018
Case type:Major Owner / responsible:National organisations
MDC:MDC11 Old forum status:
Target Grouper:COMMON

Description

Problem
DRG 315 is heterogeneous group, both clinically and economically. Three different procedure groups (properties 11S07 Other kidney or urinary tract OR procedure, 11S90 Blood vessel biopsy and 11S10 Procedures for vesicointestinal fistula) including ca 200 different procedure codes in Finnish 2017 version and influencing the grouping to DRG 315. As a result, the DRG 315 consist of different subgroups, each having different mean cost and clinical variety.
With aim to clarify the content of DRG 315 and in order to organize the cases within the group and come up with possible suggestions for changes, an analysis was conducted.

Analysis
The mean cost of DRG 315 in 2015 is 6 775 EUR and variation coefficient 154%. Total number of cases is 337.
To start with, the cases of DRG 315 were divided into clinically homogenous groups based on following procedure codes:

1.Insertion of hemodialysis catheters

a.For temporary use

i.TPH15/PHXA30 Insertion of central venous catheter through external or internal jugular vein
ii.TPH20/PHXA32 Insertion of central venous catheter through subclavian or brachiocephalic vein

b. Tunneled hemodialysis catheter

i.TPX10/PHXA20 and PHXX06 Implantation of vascular injection port

2.Construction and closure of arteriovenous fistula (different arteries)

a.Construction

i.PBL08/PBLS10 Construction of arteriovenous fistula from axillary artery
ii.PBL09/PBSL20 Construction of arteriovenous fistula from brachial artery
iii.PBL10/PBSL30 Construction of arteriovenous fistula from radial or ulnar artery (in Finnish version PBL10 is meant for fistula from radial artery)
iv.PBL11/PBSL30 Construction of arteriovenous fistula from radial or ulnar artery (in Finnish version PBL11 is meant for fistula from ulnar artery)
v.PBL99/PBSL99 Construction of other arteriovenous fistula of upper extremity
vi.PEL25/PESL10 Construction of arteriovenous fistula from femoral artery and PESL90 Construction of arteriovenous fistula in thigh (in Finnish version PEL25 is meant for fistula from femoral superficial artery)

b.Closure

i.PBM08/PBSM10 Closure of arteriovenous fistula of axillary artery
ii.PBM09/PBSM20 Closure of arteriovenous fistula of brachial artery
iii.PBM10/PBSM30 Closure of arteriovenous fistula of radial artery (in Finnish version PBM10 is meant for fistula of radial artery)
iv.PBM11/PBSM30 Closure of arteriovenous fistula of radial artery (in Finnish version PBM11 is meant for fistula of ulnar artery)
v.PBM99/PBSM99 Closure of other arteriovenous fistula of upper extremity

3.Insertion of peritoneal dialysis catheter

a.procedure code JAK10/JASK10 Laparotomy and insertion of peritoneal dialysis catheter

4.Rest of the cases in DRG 315.

The results of the analysis show that apart from clinical meaningfulness of subgroups also the economical one improves.
The initial variation coefficient of DRG 315 was 154% and it would decrease in all subgroups as follows:

1.Insertion of hemodialysis catheters 127% (# of cases 31)
2.Construction and closure of arteriovenous fistula 55% (156)
3.Insertion of peritoneal dialysis catheter 115% (45)
4.Rest of the cases 93% (105)

If to remove one of the most expensive cases in each group, the results get even better:
1.114%
2.42%
3.77%
4.76%

Suggestion
Based on the analysis we suggest to split DRG 315 into for four separate DRGs based the principles described above, i.e. separate group for:
1.Insertion of hemodialysis catheters
2.Construction and closure of arteriovenous fistula
3.Insertion of peritoneal dialysis catheter
4.Rest of the cases in DRG 315
The names of the groups 1-3 will be provided after discussions in Expertnetwork meeting. The last group would remain the current name of DRG 315 Other kidney and urinary tract o. r. procedures

DRG change
After the suggested changes the cases in DRG 315 will be separated into three new DRGs and the rest of the cases remain in DRG 315.

Technical changes
Will be provided later.

Cost analysis
Appendix 1. Cost analysis is based on five university hospital data of 2015, grouped with Finnish 2017 grouper, and data of 2014, grouped with 2016 grouper.

MDC11_Nefrology_DRG315_split_Appendix1.xlsx - Appendix 1 (17.1 KB) Kristiina Kahur, 2017-01-16 19:22

MDC11_Nefrology_DRG315_split_Appendix2.xlsx - Appendix 2 (33.7 KB) Kristiina Kahur, 2017-01-25 15:16

Appendix #503 SWE 2017.xlsx (26.8 KB) Mats Fernström, 2017-03-09 14:12

Technical changes case #503.xlsx (72.2 KB) Martti Virtanen, 2017-09-11 16:37

Technical changes case #503-2.xlsx (72.7 KB) Martti Virtanen, 2017-11-20 14:19

Technical changes case #503-3.xlsx (72.3 KB) Martti Virtanen, 2018-02-12 11:37

Technical changes case #503-4.xlsx (72.8 KB) Martti Virtanen, 2018-03-13 11:57

Technical changes case #503-5.xlsx (73.7 KB) Martti Virtanen, 2018-05-22 15:11

History

#2 Updated by Mats Fernström over 3 years ago

Mats Fernström, NPK, Sweden 2017-03-02 (NPK ID C676)
DRG 315 corresponds to DRG M29 in the Swedish version and it is the surgical rest group in MDC 11. Rest groups are almost unavoidably heterogeneous because they contain everything else that has not been grouped into more specific groups. The Swedish DRG Expert group (SWEX) has said that we should analyze all rest groups and see if they can be made smaller by moving certain diagnoses or procedures to more specific DRGs, so this proposal is in line with that ambition.
But we see problems with this special proposal. First, there will be very small groups in the Swedish version because we have already divided this DRG in three, DRG M29A (very complicated), M29C (complicated) and M29E (not complicated). For example, we have 382 cases in DRG M29E in KPP 2015. If we apply the proposed changes we will have only 8 cases in the group based on procpro 11S12 and only 31 cases in the group based on procpro 11S14. Furthermore, we think that the selection of procedures to the different suggested groups are not the best. For example, TPX10 (Implantation of vascular injection port), TPH15 (Insertion of central venous catheter through external or internal jugular vein) and TPH20 (Insertion of central venous catheter through subclavian or brachiocephalic vein) are seldom used for dialysis (according to Ralph who is a specialist in nephrology). We are also somewhat doubtful about having construction and closure of arteriovenous fistula in the same group, closure is a very simple procedure.
So we do not want this suggested change to be done in the Swedish version. We can possibly consider a smaller change like having a separate group for constructions of arteriovenous fistulas because such a group would not be too small, but we have to analyze that further.

#3 Updated by Martti Virtanen over 3 years ago

2017-03-09 Martti Virtanen
Can Sweden report the result of the splitting by non-CC/CC/MCC which is basicly a compeating model to this proposal.

#4 Updated by Mats Fernström over 3 years ago

Mats Fernström, NPK, Sweden, 2017-03-09
As requested by Martti I include our cost data for DRG M29 that corresponds to DRG 315 (Appendix #503 SWE 2017.xlsx). If you open the filter in the column “Procedure” you can see the data for all significant procedures that were present in the material. Unfortunately I don’t have had time to translate the procedure code texts but you can always find the English texts in NCSP+.

#5 Updated by Martti Virtanen about 3 years ago

  • File Technical changes case #503.xlsx added

2017-03-13 Expert group
Expert group accepted to split the DRG's as proposed However, NordDRG Swe will maintain the MCC model instead of the new split.
The technical changes document contains a list of all related NCSP+ codes and the linked codes in different versions.
The logic table illustrates the changes in the combined table. Filtering with 'Swe' will indicate that nothing changes in the Swedish version. All other versions have changes.

#6 Updated by Martti Virtanen about 3 years ago

  • File Technical changes case #503.xlsx added

2017-04-25 Martti Virtanen
I missed the fact that DRGf 315C is already in use in NordDRG Swe. Forth character 'C' is used in the common version as linkage to the NordDRG Swe CC-level complication categories. Therefore it cannot be used in the common version. I have change C->D and D->E for this case.

#7 Updated by Martti Virtanen about 3 years ago

  • File deleted (Technical changes case #503.xlsx)

#8 Updated by Martti Virtanen about 3 years ago

  • File Technical changes case #503.xlsx added

2017-06-26 Martti Virtanen
Kristiina’s note, that the cheap 315B is before expensive 315A is obviously correct. This was missed in the earlier discussions.
That can easily be corrected by moving the 315A-rules before other 315 rules.
The new ords will start with 411D1300. This will not affect other DRG’s nor the NordDRG Swe.

There is another more complicated problem. Almost all interventions with 11S13 and 11S14 (and also 11S12) have already 11S07. This makes the new rules impossible to apply since the rules with 11S13 and 11S14 are placed after the rules with 11S07.
Removal of 11S07 will change the grouping in the NordDRG Swe.

For both variants to work, we ned to give a new property 11S15 ‘ Other kidney or urinary tract OR procedure’ that will be used by the other versions than Swe and retain 11S07 ‘Other kidney or urinary tract OR procedure’ for the NordDRG Swe. (Since any version is using either 11S07 or 11S15 they may have the same name?) The new property 11S15 is given to all interventions with 11S07 except those with 11S12, 11S13 or 11S14.
The rules of other versions than NordDRG Swe will be changed to use 11S15 instead of 11S08.

#9 Updated by Martti Virtanen about 3 years ago

  • File deleted (Technical changes case #503.xlsx)

#10 Updated by Kristin Dahlen almost 3 years ago

After further analysis, we have determined that the split of DRG 315 shall not be implemented in the Norwegian Version for 2018.

#11 Updated by Martti Virtanen almost 3 years ago

  • File Technical changes case #503.xlsx added

2017-08-28 Martti Virtanen
Because of the Norwegian decission, the technical changes needed to be modified. The old rules are maintained for Norway.

#12 Updated by Martti Virtanen almost 3 years ago

  • File deleted (Technical changes case #503.xlsx)

#13 Updated by Martti Virtanen almost 3 years ago

2017-09-11 Martti Virtanen
This proposal has a few lines where a second rule for the same DRG repeats a first rule with an additional property.
Since the first rule already cathers all potential cases, these rules do not function and shall be omitted.
The rules are marked in the new technical changes table.

#14 Updated by Martti Virtanen almost 3 years ago

  • File deleted (Technical changes case #503.xlsx)

#15 Updated by Martti Virtanen over 2 years ago

2017-11-20 Martti Virtanen
Kristiina Kahur reported from Finnish testing, that some cases that formerly were assigned to DRG 315O are now assigned to DRG 477O.
All cases have intervention PBL10 (PBSL30) 'Construction of arteriovenous fistula from radial or ulnar artery'.
The problem is, that in the orginal Finnish proposal now changes were proposed for outpatient/short therapy grouping. However, in techical changes the property 11S07 was in the logic substituted by 11S15 that among others PBSL30 does not have. The result is the grouping to 477O.

This error affects all versions except SWE.

Attached is the new version of technical changes. In the corrected logic-sheet the changes are marked with orange background.
The Fin version will be corrected. If the correction is demanded by other countries (Est, Ice, Lat, Nor) the produced versions groupers will be reproduced.

#16 Updated by Martti Virtanen over 2 years ago

2018-02-12 Martti Virtanen
Norway will retain the old grouping. To allow this the old rules with 11S07 are reinserted for Nor version only.
This is OK in the Technical changes.

The old rule 411D141110 (Com/Den/Est/Ice/Lat)has by misstake retained the DRG 315(X) that is no more valid for these versions.
The Icelandic version has a misstake a new rule with DRG 315(X) instead of DRG 315B
These are now corrected in the technical changes.

This error causes the problem that especially in Ice version some cases will have DRG 315(X) instead of 315B. In the Estonia and Latvia it only affects cases grouped because of anaeshesia (property 00X10).
We will deliver new groupres if wished by the countries.

#18 Updated by Martti Virtanen over 2 years ago

  • File Technical changes case #503-4.xlsx added

2018-03-13 Martti Virtanen
One more correction.
Interventions with 11S15 are not allways OR=1 and therefore the anaesthesia rule (with 00X10) is valid and needed.
It is now added to correct place in a new technical changes.

#20 Updated by Martti Virtanen over 2 years ago

  • File deleted (Technical changes case #503-4.xlsx)

#21 Updated by Martti Virtanen about 2 years ago

2018-05-22 Martti Virtanen
Discussion with Finland has revealed still problems with this case.
For outpatients some cases that used to be assigned to DRG 315O are now assigned to DRG 477O. This was partly corrected already last year, but there are still some cases.
The reason is that there are 12 codes that have 11S07 but do not have 11S15 (marked with light red (rosa) in Proc-sheet of technical changes). However, all codes with 11S15 have 11S07.

Rules must exist both for cases with MDC 11 and cases with PDGPROP 11P01. And for other versions than Nor for cases OR=S and for casis with anaesthesia (00X10)

Not wanting make things further complicated:
Nor will use only 11S07 for both inpatient and outpatient rules. No rules with anaesthesia (00X10) are included.
Com/Den/Est/Fin/Lat will use only 11S07 for outpatient rules. Both OR=S and anaesthesia rules are included. For inpatients only 11S15 is used.
Swe will use only 11S07 with their specific rules.

See technical changes drglogic sheet for details. The changes are marked light red. Some ---(OUT) (not out) have nat_vers changes.

#22 Updated by Martti Virtanen over 1 year ago

2018-03-13 Expert group
This case is partly continued in case #570. The basic model is accepted and even the proposal in case #570 was accepted.

However, not that there is still a misstake that is included as a new question as case #612!

This case is now closed.

#23 Updated by Martti Virtanen over 1 year ago

  • Status changed from Further active to Accepted

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