Case #541

Combined groin hernia operations

Added by Mats Fernström over 4 years ago. Updated over 3 years ago.

Status:AcceptedStart date:2017-02-22
Priority:MinorSpent time:-
Assignee:Mats Fernström
Category:-
Target version:Target version 2018
Initiator:Sweden Target year:2018
MDC:MDC06 Owner / responsible:National organisations
Target Grouper:COMMON, DEN, EST, FIN, ICE, LAT, NOR, SWE Old forum status:

Description

Problem
Outpatient operations of unilateral groin hernia are in the Swedish version grouped to DRG F24O ’Operationer av unilaterala inguinala och femorala bråck, öppenvård’ (former DRG 162O ‘Inguinal & femoral hernia procedures, short therapy) with the weight 0,51 for 2017. If another hernia is repaired in the same session, e.g. an umbilical hernia, the case will be grouped to DRG F20O ’Operationer av andra bråck än inguinala och femorala, öppenvård’ (former DRG 160O ‘Hernia procedures except inguinal & femoral, short therapy’) with the weight 0,41 for 2017. Thus, the combined operation of both groin and umbilical hernias leads to a DRG with a lower weight compared to operation of just the groin hernia. This is obviously wrong and it depends on an incorrect hierarchy in the table Drglogic. We don’t know if this problem exists also in other national versions.
Analysis
NPK, Sweden – 2017-02-14
The DRG weights are based on average costs so we started the analysis by looking at the costs for the last three years to exclude the possibility that the weight difference was temporary, see table 1 in Appendix C690.xlsx. As seen in table 1, the cost relations were constant; DRG F24O/162O was more expensive than DRG F20O/160O all three years.
In the analysis we found that cases with combined operations of both groin and other hernias within DRG F20O/160O accounted for 5% of the total number and the average cost for these combined cases was 76-62 % (depending on trimming or not) more expensive than the others. Furthermore, the cases with combined operations of both groin and other hernias within DRG F20O/160O had an average cost that was almost identical to the average cost for DRG F25O ’Operationer av bilaterala inguinala och femorala bråck, öppenvård’ (former DRG 162P ‘Inguinal and femoral hernia procedures, bilateral, short therapy). All cost data are visualized in table 2 in Appendix C690.xlsx.
Based on these data, Sweden has decided to not only fix the hierarchy in Drglogic according to cost levels, but also move cases with combined operations of both groin and other hernias from DRG F20O/160O to DRG F25O/162P with the new text “Operation av ljumskbråck, bilateralt eller kombinerat med annan bråckoperation, öppenvård”. A suitable English text could be “Inguinal and femoral hernia procedures, bilateral or combined with other hernia procedures, short therapy”.
Decided changes
NPK, Sweden – 2017-02-14
Sweden has decided to change the hierarchy in Drglogic for DRG F20O/160O according to cost levels, which means that the rule for that DRG is moved to a place immediately after the rule for DRG F24O/162O. We have also decided to move cases with combined operations of both groin and other hernias from DRG F20O/160O to DRG F25O/162P with the new text “Operation av ljumskbråck, bilateralt eller kombinerat med annan bråckoperation, öppenvård”.
DRG change
Cases with combined operations of both groin and other hernias will go from DRG F20O/160O to DRG F25O/162P. It is about 100 to 200 cases per year.
Technical change
In the table Drglogic, the existing rule for DRG F20O/160O with ORD 106D080000 is moved to a place after the rule for DRG F24O/162O with ORD 106D091000.
Also in the table Drglogic, a new rule is inserted immediately after the rule for DRG F25O/162P with ORD 106D090000. This new rule is a copy of the rule with ORD 106D090000 but DGPROP 99X04 is deleted and PROCPRO 06S09 is inserted in the field SECPROC.
In the table Drgnames, the text for DRG F25O/162P is changed to “Operation av ljumskbråck, bilateralt eller kombinerat med annan bråckoperation, öppenvård”. The short text is changed to “Op ljumskbråck bilat/komb O”.
Detailed technical changes according to the NCC Excel template are in Decision C690.xlsx.

Appendix C690.xlsx (14.3 KB) Mats Fernström, 2017-02-22 12:48

Decision C690.xlsx (17.4 KB) Mats Fernström, 2017-02-22 12:48

#541.xlsx - #541 (12.6 KB) Kristiina Kahur, 2017-03-03 14:49

New Decision #541 C690 20170406.xlsx (18.5 KB) Ralph Dahlgren, 2017-04-06 08:05

Technical changes case #541.xlsx (28.1 KB) Martti Virtanen, 2017-04-11 17:35

History

#1 Updated by Kristiina Kahur over 4 years ago

Finnish National DRG-centre 2017-2-28

Can you explain what does it mean in Appendix C690 where in rows 12 and 13 is indicated “F20O (160O) with JAB and JAC”? DRG F20O is meant for Hernia procedures except inguinal & femoral and cannot contain JAB and JAC procedures. Is there any mistake or it comes from the differences between national versions or the reason is something else?
In Finnish version procedure codes from JAB (inguinal) and JAC (femoral) have property 06S08 (Inguinal or femoral herniotomy) and are linked to DRG 162O (F24O) or 162P (F25O) if bilateral.
F20O (160O) is meant for Hernia procedures except inguinal & femoral and it cannot include JAB and JAC procedures as indicated in the appendix.

#2 Updated by Mats Fernström over 4 years ago

Mats Fernström, 2017-02-28
Thank you Kristiina for reading or suggestion. The grouper compares the patient data with the demands in Drglogic, rule after rule according to the order (ORD), until there is a match. The rule for DRG F20O/160O (Hernia procedures except inguinal & femoral, short therapy) demands procedures with procpro 06S09, which certainly is not inguinal & femoral hernia procedures (JAB & JAC procedures with procpro 06S08) as you say, but the rule does not say that additional procedures with procpro 06S08 are forbidden. In the Swedish version the rule for DRG F20O/160O comes before the rules that handle inguinal & femoral hernia procedures (06S08) which means that not only cases with 06S09 alone, but also cases with the combination of 06S09 and 06S08, are grouped according that rule. The expression “F20O with JAB & JAC” stands for the cases that have the combination of 06S09 and 06S08. I don’t know the order of the rules in the Finnish version, but if the rule for DRG 160O comes before the rule for DRG 162O you probably also have some cases in DRG 162O that are operated for both groin hernia and another hernia.

#3 Updated by Kristiina Kahur over 4 years ago

Kristiina Kahur 2017-2-28

Thanks Mats for clarification. It explains the content of the Appendix. We will work further on with your suggestion. Thanks.

#4 Updated by Kristiina Kahur over 4 years ago

Finnish National DRG-centre 2017-3-3

First, the cost-weights in Finland are the opposite when it comes to DRGs F24O/162O and F20O/160O. In Sweden the cost-weights are 0,51 and 0,41 while in Finland 3,38 and 3,75 respectively.
Second, we replicated the Swedish table and filled it with Finnish cost data (see appendix # 541).
-we got very similar results with regard to proportion of cases in F20O/160O with JAB and JAC (in fact there was no cases with JAC in DRG F20O/160O in Finland) – it is 5% in Sweden and 6% in Finland.
-we learned that the mean cost of cases with JAB and JAC are more expensive than mean cost w/o in DRG F20O/160O. The difference in Finland is ca three times less though compared to Sweden (in case of untrimmed cases 14% vs 75%)
-the comparison of mean cost of the cases in DRG F20O/160O and F25O/162P is opposite to Swedish results, i.e. the cases in DRG F25O are ca 1/3 more expensive than the case in DRGF20O/160O with JAB and JAC, while in Sweden the same cases were 10% less expensive.
Third, Finnish cost data do not fully support the Swedish proposal. The mean cost of the cases in DRG F20O/160O with JAB and JAC are somewhere between F20O/160O w/o JAB and JAC and F25O+F20O with JAB and JAC.
Therefore neither the change in ord hierarchy nor the regrouping the cases with combined operations to DRG F25O/162P are supported based on Finnish data.

#5 Updated by Mats Fernström over 4 years ago

Mats Fernström 2017-03-04
Thank you for the Finnish data. On the meeting, we should not waste time on discussions about the order. It is up to each country to decide the order in its own Drglogic and Sweden must change the order. We cannot have the situation where addition of another significant procedure results in a DRG with lesser weight.

#6 Updated by Martti Virtanen over 4 years ago

2017-06-08 Martti Virtanen
The rules at issue have been reorderd at some point because 06S09 is before 06S08.
There migth be aproblem with the interventions belongint to 06S09. Some of them are obviously quite heavy while others are minor interventions. Probably the spectrum of outpatient interventions are different in Sweden and Finland.

#7 Updated by Ralph Dahlgren over 4 years ago

While going through the cases when making technical changes for the Swedish definitiontables we notet that in Mats technical Changes named "Decision C690.xlsx" the are an error in the table DRGlogic concerning the ord value.
The ord "IN" for DRG F25O 106D090010 is already used in the commonversion by Norway. So the ord will be changed to 106D090020. See the file "New decision #541 C690 20170406.xlsx"

#8 Updated by Martti Virtanen over 4 years ago

  • File Technical changes case #541.xlsx added

2017-03-13 Expert group
Reimbursemetn for a patient with operation on both groin hernia and other hernia cannot be less than only groin hernia.
Change created by changes of logic order.
In Finland the results were somewhat different but not that much. In Sweden the cost differences are bigger.
Accepted for all versions.
Technical changes to be adjusted for all versions.

#9 Updated by Martti Virtanen over 4 years ago

  • Target Grouper COMMON, DEN, EST, FIN, ICE, LAT, NOR added

#10 Updated by Martti Virtanen over 4 years ago

2017-04-11 Martti Virtanen
My understanding is that the changes were accepted for all versions.
I realized also that Nor and Ice versions had a small error, since there were repeating rules with the same content. The second rules are impossible, no cases can be assinged accrding to them.
The new Technical changes document correct also these errors and gives all rulws corret ord-codes.

#11 Updated by Martti Virtanen over 4 years ago

  • File deleted (Technical changes case #541.xlsx)

#13 Updated by Kristiina Kahur over 4 years ago

Finnish National DG-centre/Kristiina Kahur 2017-4-12

According to my notes, it was decided in Riga meeting that the proposal was accepted for SWE, ICE and NOR. Finland made analysis (see the post from 3rd of March 2017) and the results did not support that change.

#14 Updated by Kristin Dahlen over 4 years ago

According to the description of the case, wouldn't it be right to put the rule for DRG 160O behind the rules for DRG 162P? As I understand it this is the way it is done in the Swedish description?

#15 Updated by Mats Fernström over 4 years ago

Mats Fernström, NPK, Sweden, 2017-06-08
You are right Kristin but that is also what is written in the technical changes done by Martti. Maybe you looked at the ID instead of the ORD.

#16 Updated by Martti Virtanen over 3 years ago

  • Status changed from Active to Accepted

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