Case #516

Rearranging the cases in DRG 038O Primary iris procedures, short therapy and 042O Intraocular procedures except retina iris and lens, short therapy

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

Status:AcceptedStart date:2017-01-23
Priority:NormalSpent time:-
Assignee:Hanne Osnes-Ringen
Category:-
Target version:Expert Group 2017
Initiator:Norway Target year:2018
MDC:MDC02 Owner / responsible:National organisations
Target Grouper:SWE Old forum status:

Description

Problem
While analyzing the DRGs of MDC 2 Diseases and disorders of the eye, we captured two DRGs with some problems in terms of homogeneity and clinical content. DRG 038O is a heterogeneous group with variation coefficient 175% in 2015 (142% in 2014). DRG 042O seems to be ok when it comes to V% (ca 50%), but the histogram shows different peaks within the group which altogether balance the V% of the group. The content wise both DRGs are dealing with intraocular structures of eye .
The analysis was carried out to find the reasons for abovementioned problems and come up with suggestion to change the logic and make it clinically and economically more relevant.

Analysis
To start with, the cases of DRG 038O and 042O from 2014 and 2015 were pooled into one. The main focus was on subgroups within the pooled cases in order to find relation between cost and clinical issues.
Based on the analyzes we were able to differentiate four different groups of cases which would make sense in terms of clinical and economical meaningfulness:

1. Laser procedures on iris and chamber angle

a. CHD00/CHSD00 Laser trabeculoplasty
b. CHD05/CHSD05 Selective lasertrabeculoplasty
c. CHD35/CHSD35 Laser goniopuncture
d. CHC03/CHSC03 Laser iridoplasty
e. CHC05/CHSC05 Laser iridotomy

2. Procedures on intraocular pressure

a. CHD15/CHSD15 Trabeculectomy and iridectomy
b. CHD50/CHSD50 Shunt operation on anterior chamber
c. CHD60/CHSD60 Deep sclerectomy without implant
d. CHD65/CHSD65 Deep sclerectomy with implant
e. CHD99/CHSD99 Other filtering operation

3. Transplantation of cornea

a. CGG30/CGSG30 Anterior lamellar transplantation of cornea
b. CGG31/CGSG31 Posterior lamellar transplantation of cornea
c. CGG40/CGSG40 Full thickness transplantation of cornea using autograft
d. CGG45/CGSG45 Full thickness transplantation of cornea using homograft

4. Rest of the cases of intraocular procedures (remaining cases of pooled 038O and 042O)

The mean cost, V% and number of pooled cases of DRGs 038O and 042O in 2015 are 992 EUR, 113% and 4 637 (in 2014 1 133 EUR, 103%, 4 012).
The same results of four new groups in 2015 (in 2014) are as follows:

1. Laser procedures on iris and chamber angle

a. 215 EUR, 53%, 2 669 (249 EUR, 47%, 2 058)

2. Procedures on intraocular pressure

a. 2 200 EUR, 25%, 640 (2 090 EUR, 23%, 618)
3. Transplantation of cornea
a. 4 886 EUR, 17%, 68 (5 252 EUR, 14%, 81)

4.Rest of the cases of intraocular procedures

a. 1 816 EUR, 52%, 1 260 (1 846 EUR, 51%, 1 255)

The results of rearrangements show that the new groups are cost homogenous, and have reasonable number of cases.
Since considerable number of the outpatient cornea transplantation cases are currently grouped also to DRG 041O and 039O (in addition to DRGs 042O and 038O), there is created a separate case #517 in the ticketing system which suggest creating a new DRG for outpatient cornea transplantation cases.

Suggestion
Based on the analysis of DRGs 038O and 042O we propose to rearrange the logic so that there will be four new DRGs for short therapy cases divided by the clinically relevant groups (based on groups of procedures):

1. Laser procedures on iris and chamber angle
2. Procedures on intraocular pressure
3. Transplantation of cornea (see also separate case in ticketing system because it concerns also some other MDC2 outpatient DRGs)
4. Rest of the cases of intraocular procedures in DRGs 038O and 042O, will be merged into one, 042O Other intraocular procedures, short therapy.

DRG change
After the suggested changes the cases currently in DRGs 038O and 042O will be grouped to separate DRGs depending on the performed procedures.

Technical changes
Appendix 2. The technical changes may contain mistakes and have to be used with caution.
NB! The file does not include the technical changes regarding transplantation of cornea, they will be provided with separate case #517, which suggest creating a new DRG for outpatient cornea transplantation cases.

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 Finnish 2016 grouper.

MDC2_Oftalmology_Rearr_DRGs_038O_042O_Appendix1.xlsx - Appendix 1 (12.8 KB) Kristiina Kahur, 2017-01-23 17:35

MDC2_Oftalmology_Rearr_DRGs_038O_042O_Appendix2.xlsx - Appendix 2 (31.9 KB) Kristiina Kahur, 2017-01-23 17:35

Swedish changes of NCMC technical changes #509 - #517 20170427.xlsx (20.8 KB) Ralph Dahlgren, 2017-04-27 16:18

Technical changes case #509-517.xlsx (65.5 KB) Martti Virtanen, 2017-05-02 14:47

Technical changes case #509-517-2.xlsx (66.4 KB) Martti Virtanen, 2017-06-15 14:05

TC_#516_C700.xlsx (14.7 KB) Mats Fernström, 2017-12-20 18:01

Technical changes case #509-517-4.xlsx (68.2 KB) Martti Virtanen, 2018-12-03 11:52

History

#1 Updated by Mats Fernström over 4 years ago

Mats Fernström, NPK, Sweden 2017-03-09 (NPK ID C700)
We have already supported the creation of group 3 (Transplantation of cornea) in case #517.
DRG 038O corresponds to the Swedish DRG B11O and DRG 042O corresponds to the Swedish DRG B20O.
Group 1 (Laser procedures on iris and chamber angle) will in Swedish KPP have 4 106 cases with an average cost 2 300 SEK. The cases are coming from DRG B11O/038O (Primary iris procedures, short therapy) where the average cost is 2 704 SEK (4 334 cases). Thus there will be enough cases in the new group but the average cost will only differ by 18 % from the present DRG B11O. We can support creation of this group if it is clinically meaningful. Have you discussed it with ophthalmology specialists?
Group 2 (Procedures on intraocular pressure) will in Swedish KPP have 1 023 cases with an average cost 11 999 SEK. The cases are coming from DRG B20O/042O (Intraocular procedures except retina iris & lens, short therapy) where the average cost is 10 983 SEK (3 166 cases). Also here there will be enough cases in the new group but the average cost will only differ by 9 % from the present DRG B20O. We can support creation of this group if it is clinically meaningful. Have you discussed it with ophthalmology specialists?
If group 1 is created there will be only 228 cases left in DRG B11O/038O and the average cost for this rest will be 9 985 SEK.
If group 2 and 3 are created there will still be 2 096 cases left in DRG B20O/042O but the average cost for this rest will be reduced to 9 981 SEK. The relatively small number of cases in DRG B11O/038O and the very similar cost compared to DRG B20O/042O speak for a merging of these Groups just as it has been proposed for the corresponding inpatient groups in case #510.
In summary: We support this suggestion, provided that it is supported by the profession but then also DRG B11O/038O should be merged to DRG B20O/042O like it is proposed to be for the corresponding inpatient DRGs in case #510.

#2 Updated by Kristiina Kahur over 4 years ago

Finnish National DRG-centre 2017-3-9

Just a quick comment about the involvement of specialtists in grouper development work - all suggestions submitted by Finland on areas of ophthalmology, nephrology, urology and burns have been discussed with specialists of respective area and also accepted by them.

#3 Updated by Martti Virtanen over 4 years ago

2017-03-13 Expert group
Expert group accepted the proposal. Technical changes need checkup.

#4 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #516.xlsx added

2017-04-24 Martti Virtanen
In short this combines DRG 038O and 042O to one DRG (042P) with the expecption of cases for 'Laser procedures on iris and chamber angle, short therapy' (036R) and cases for 'Procedures on intraocular pressure, short therapy' (036S).
The inpatient cases DRG-assignment will not change.
The change is valid for all versions of NordDRG.

Case #517 for DRG 036P 'Transplantation of cornea, short therapy' is closely reated and partly included in the technical changes tables.

The change is reached by addition two new properties (02S30 and 02S31), see proc.prop sheet of Technical changes. The proposed 03S32 'Other Intraocular procedures' is not needed because the order of the rules takes care of this matter.
In the DRG logic each version gets two new rules for the DRG's 036R and 036S. For the rules of DRG 038O and 042O the DRG is changed to 042P.
In addition thow technical errors of the combined logictable are corrected. They do not affect the DRG assigment.

Technical changes include changes for #case 517. The logic and ncsp+ tables include information about related rules.

The names and national codes are to be decided by the national organisations.

#5 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #514-517.xlsx added

2017-04-25 Martti Virtanen
The cases #509, #514, #515, #517 and #517 are all about ophtalmology and the changes are related. Therefore the technical changes are now combined for those cases. For the changes the cases are referenced in the tables. The tables include extraneous information for checkup of the process. Those lines are not linked to any case and have '---' in IN/OUT column.
In the process I found a few errors in the common logic structure and I have corrected the at the same time.
In case #517 the proposed removal of 02S03 and 02S04 is a misstake. It is marked with yellow and with 'No' in IN/OUT column.

#6 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #516.xlsx)

#7 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #514-517.xlsx)

#8 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #514-517.xlsx added

#9 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #514-517.xlsx)

#10 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #509-517.xlsx added

#11 Updated by Ralph Dahlgren over 4 years ago

2017-04-27.
Sweden has gone through Finnish cases #509-#517 again and also the technical changes done by Martti.
#515 and #517 concerns Sweden, not the others.
We want to make some changes and corrections in Marttis technical changes since we do not agree on everything.
enclosed is a Excel-file “Swedish changes of NCMC technical changes #509 - #517 20170427.xlsx”.
There are 3 sheets in the file.
In the sheet DRGlogic we want to change the ord value for the new NCMC DRG 036R (Swedish DRG B08O Annan op för högt ögontryck O) and DRG 036S (Swedish DRG B07O Stor op för högt ögontryck O).
That is due to the fact that DRG B08O is more expensive that B07O.
In the sheet proc Sweden has added some procedure codes that we want to have 02S30 or 02S31.
This due to the fact that in the Finnish case they included some of the Swedish procedures about the same medical problem but not all.
Sweden therefore wants to include another 5 procedure codes into the case. We cannot see why they are excluded in the case. Some we have economic data about some and they fit very well into the case but others just out of a medical perspective since it concerns the same disease and treatment.
If this is not accepted by other countries let us know and we will make other technical changes to include the procedure codes by creating a new pro proc prop and 2 new lines in drglogic.
And in last sheet the Swedish drgnames are included.

#12 Updated by Kristiina Kahur over 4 years ago

Kristiina Kahur/Finnish National DRG-centre 2017-4-28

We do not see any obstacle if Sweden will have different technical changes in current situation. There are other areas where the national versions differ from each other, that one just proves the rule.

#13 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #509-517.xlsx added

2017-05-02 Martti Virtanen
In addition to the Swedish names for the new DRG's that we obviously need, Sweden detected two errors in the defintion tables.
The Proc (and NCSP+) tables did not include the codes in the CHSD-group that are not in use in Finland. They must obviously get the properties as proposed by Ralph.
The Finnish data also indicates that the laser-intevention cases are less expensive than the other cases at issue. This is intuitively correct and all versions must have the same order.
The finnish proposal had also missed Disch=N and dur <2 values. I had missed to add Disch=N that is our general principle in short therapy from the beginning of this system.

The combined NordDRG Com is updated. - note that the ord and id of rows need only to be switched for 102D018000-102D019000!

#14 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #509-517.xlsx added

#15 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #509-517.xlsx)

#16 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #509-517.xlsx)

#17 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #509-517.xlsx)

#18 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #509-517.xlsx added

#19 Updated by Martti Virtanen over 4 years ago

2017-05-02 Martti Virtanen
One more correction from Liselotte. These rows are identical and after each other:
IN 102D020001 102D020001 Fin 042P Other Intraocular procedures, short therapy
IN 102D020100 102D020100 Com/Den/Est/Ice/Lat 042P Other Intraocular procedures, short therapy
Thus the NordDRG Fin rule can be combined with the other rule.

#20 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #509-517.xlsx)

#21 Updated by Ralph Dahlgren over 4 years ago

2017-05-03 Ralph Dahlgren
Sweden has gone through the Technical changes done by Martti 2017-05-02 called “Technical changes case #509-517.xlsx.” kl.13.48.
There are some errors that have to be corrected.
First in the sheet DRGlogic there has to be a change for the column “dur” from <2 to <1. Sweden has <1 so this is just a minor adjustment This concerns the new 036R (Swedish DRG B08O Annan op för högt ögontryck O) and DRG 036S (Swedish DRG B07O Stor op för högt ögontryck O) ord: 102D0180001 and 102D0190001.
Then there has to be a correction in the sheet procpro. The procedure code CHD05 Selektiv lasertrabekuloplastik should have the grouping property PROCPR 02S30 added and not 02S31.

#22 Updated by Martti Virtanen over 4 years ago

2017-06-16 Martti Virtanen
Ralph has obviously right.
In addition CHSD40 had wrong text (that of 02S30).
In logic table two rules had stil DRG 042O instead of 042P (102D0401001 for Swe and 102D040100 for Com/Den/Est/Ice/Lat)
The technical changes is corrected for these.

#23 Updated by Hanne Osnes-Ringen about 4 years ago

  • Assignee changed from Kristiina Kahur to Hanne Osnes-Ringen
  • Priority changed from Major to Normal
  • Initiator Norway added

Norway has gone through the technical changes and the regrouping do to the changes in the eye DRGs.

There are a few questions.

Question 1:
The following codes:
CHD00 Lasertrabekuloplastikk
CHD05 Selektiv lasertrabekuloplastikk
CHD30 Lasertrabekulektomi
CHC05 Laseriridotomi
have both the grouping property 02S30 and 02S06 , is the last one necessary?
Question 2:

The codes:
CHB00 Lasersynekiolyse
CHE05 Laserpupillotomi
CHE20 Laserterapi av lesjon i iris

These codes only have the property 02S06 and are grouped to DRG42P, instead they should have the property 02S30 and be grouped to DRG 36R which contains similar procedures.

Question3:
The codes
CKC00 Laservitreolyse
CKC12 Transpupillær laserbehandling av retina
CKC20 Cryopeksi av tilliggende retina
CKC40 Elektrokoagulasjon av retina
in the DRG group 36E are quite different from the other procedures in the DRG 36E, both concerning costs and time, should they be moved to another DRG?

#24 Updated by Mats Fernström almost 4 years ago

Mata Fernström, NPK Sweden 2017-12-20
Answers to the questions from 2017-09-01 by Hanne Osnes-Ringen:

Answer to question 1: Yes, 02S06 is needed for the grouping of inpatients to DRG B20 (former DRG 042).

Answer to question 2: Sweden has very few cases with CHB00 and CHE05 and no case with CHE20 in the cost database for 2016. In a cost perspective, these cases fit better in DRG B08O (DRG 36R in Norway) than in the present DRG B20O (DRG 42P in Norway). Thus we support the suggestion to add 02S30 to these procedure codes. See the Excel file TC#516_C700_.

Answer to question 3: DRG B04N (36E in Norway) contains approx. 40 procedure codes but the CV is rather low, only 37 %, in the Swedish cost database for 2016 and we see no reason to split the group. And we don’t see why just the four codes mentioned by Hanne should be transferred to another DRG. There are many more codes that differ more than 20 % from the average of the whole DRG. And we don’t see what DRG that should be better. So please, if you want a change, be more specific.

#25 Updated by Martti Virtanen almost 4 years ago

  • Status changed from Active to Further active

#26 Updated by Martti Virtanen over 3 years ago

2018-02-20 Martti Virtanen
The proposal for additional change (Question 2) needs to be discussed in Reykjavik.

The codes at issue are
CHSB00 Laser synechiolysis
CHSE05 Laser pupillotomy
CHSE20 Laser therapy of lesion of iris

CHSB00 does not exist in Finnish CSP, the other are in all versions.
The addtion of property 08S30 would move cases with these interventions to DRG 036R(B08O) 'Laser procedures on iris and chamber angle, short therapy' from DRG 042P (B20O)'Other Intraocular procedures, short therapy'

At least Finish comments are needed.

#27 Updated by Kristiina Kahur over 3 years ago

Finnish National DRG-Centre 21-2-2018

in 2016, code CHSE05/CHE05 has been used only once, code CHSE20/CHE20 has not been used at all. In 2015 none of the codes has been used. Therefore we cannot make adequate cost analysis. From clinical point of view they would fit better to DRG 36R.
We support adding PROCPRO 02S30 to those two procedures. Shouldn’t the PROCPRO 02S06 removed at the same time?

#28 Updated by Kristiina Kahur over 3 years ago

Kristiina Kahur wrote:

Finnish National DRG-Centre 21-2-2018

in 2016, code CHSE05/CHE05 has been used only once, code CHSE20/CHE20 has not been used at all. In 2015 none of the codes has been used. Therefore we cannot make adequate cost analysis. From clinical point of view they would fit better to DRG 36R.
We support adding PROCPRO 02S30 to those two procedures. Shouldn’t the PROCPRO 02S06 be removed at the same time?

#29 Updated by Mats Fernström over 3 years ago

Mats Fernström, NPK Sweden 2018-02-22
As I answered to Hanne 2017-12-20; 02S06 is needed for the grouping of inpatients to DRG B20 (former DRG 042).

#30 Updated by Kristiina Kahur over 3 years ago

Kristiina Kahur 23-2-2018

Thank Mats. And sorry, I overlooked it.

#31 Updated by Martti Virtanen almost 3 years ago

2018-03-13 Expert group
Expert group accepted the addition proposed by Mats Fernström 2017-12-20.
Lates version of Technical changes includes these additions.
The case is closed.

Also available in: Atom PDF