Case #179

Updated by Martti Virtanen almost 6 years ago

Title: MDC24 (Multiple significant trauma)
CPK ID: 2014/01
Forum ID: If known (i.e. in reactivation of an old case)
Initiated (date):4.11.2013
Initiator: National DRG Centre in Finland / Kristiina Kahur, Minna-Liisa Sjöblom
Responsible at NPK: Kristiina Kahur, Minna-Liisa Sjöblom
Sent to NordDRG Forum (date): …..1.2014
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*Problem*

Finnish national DRG-center in cooperation with Finnish traumatologists and orthopedists has carried out the analyses in order to revise the DRGs in MDC24 (Multiple significant trauma). The logic of that MDC has not been revised and changed since the NordDRG system was implemented (mid 1990s). However, there is clear need for this as the current logic in many occasions doesn’t reveal the clinical meaningfulness and homogeneity of costs. The work started in May 2012.

*Analysis*

For initial analysis the data of 5 university hospitals of Finland from year 2011 was used. For grouping the test grouper was created by Nordic Casemix Center. In later phase the test grouper was updated and for grouping Finnish 2014 Full version and the data of 5 university hospitals of Finland from year 2012 were used.

To start with, the multiple significant trauma (MST) case was defined. According to this the MST case is the one where at least two diagnoses are codes starting with first letter S from ICD-10 Chapter XIX (Injury, poisoning and certain other consequences of external causes) (S00-T98) are coded.
There were ca 5 200 cases in database responding to the definition of MST case. After grouping these cases with test grouper we ended up with 610 MST cases (n=610).

During the revision process the following steps were taken:

1. +Revision of diagnosis list used for MST grouping logic+.

The NordDRG grouping multiple trauma is defined as a combination of trauma in at least two different anatomical areas represented by a diagnosis of significant trauma in the area at issue. Currently there are 8 such anatomical areas (with dgprop 24X10-24X80) and additionally a group of diagnoses that without any combination indicate multiple trauma (with dgprop 24X90). This model is represented in the NordDRG manual [[http://www.norddrg.net/norddrgmanual/NordDRG_2012_FIN/Flow/MDC_21_10.htm]].

The analysis with Finish national data revealed that not all combinations are resource intensive. The dx for multiple trauma (24X90) where very rarely used and could not be confirmed to be associated with high resource use either.

After analysis we propose following changes to the components of multiple trauma. All current diagnosis properties for components of multiple trauma (24X..) except 24X40 will be inactivated.

* Severe intracranial trauma S06.1-3, S06.7-9 (24X11)

* Thorax major injury except spine S22 – S29 (excl S22.0 and S22.1, S23.0 and S23.3) (24X21)

* Fracture or sprain of thoracic spine S22.0, S22.1, S23.0 and S23.3 (24X22)

* Intra-abdominal major trauma S35-S39 (excl S37, S38.0 and S38.2) (24X31)

* Fracture, dislocation or sprain of lumbar spine S32.0, S32.1, S33.0, S33.1 ja S33.5 (24X41)

* Significant kidney trauma S37.0 (24X40 – existing property)

* Pelvic major trauma except spinal S32-S34 (excl S32.0 and S32.1; S33.0, S33.1 and S33.5 - incl. sacrum) (24X61)

* No diagnosis will be assigned to MDC 24 alone. The dx now belonging to dg category 24M99 will belong to dg category 21M01. Since it is unclear which organ the dx refers to, they will not have any multiple injury properties – the property 24X90 will not be used in the logic and thus it will be inactivated.

The complete lists with all diagnoses are attached in +Annex 1+.

A new principal diagnosis property (PDGPRO) 24P01 ‘Multitrauma dx’ is created. It includes all diagnoses of the components of multitrauma (diagnosis with the diagnosis properties 24X11, 24X21, 23X22, 24X31, 24X40, 24X41 and 24X61).

2. +The revision of procedure lists used for MST grouping logic+.

After revision we suggest to keep the current four procedure lists with specific procedure property as they are but separate some of procedure codes from current list 21S09 and create one additional one.

Hence, we suggest having five procedures properties with respective MST procedure codes:

* 21S03 Hand procedure for injuries – has independent use in the cases without multiple trauma and must be retained for those purposes [[http://www.norddrg.net/norddrgmanual/NordDRG_2012_FIN/Flow/PRO_21S03.htm]]

* 21S04 Craniotomy for trauma – has independent use both in the cases with and without multiple trauma and must be retained for those purposes [[http://www.norddrg.net/norddrgmanual/NordDRG_2012_FIN/Flow/PRO_21S04.htm]]

* 21S05 Limb reattachment or hip or femur procedure for trauma – is currently used in cases without multiple trauma only as an alternative to 21S09 and could be combined to 21S09 when the use for multiple trauma cases assignment will end [[http://www.norddrg.net/norddrgmanual/NordDRG_2012_FIN/Flow/PRO_21S05.htm]]

* 21S07 Lumbar, pelvic or femur fracture procedure - new property with following NCSP+ codes (Finish national codes): NASJ14 (NAJ30), NASJ15 (NAJ32), NESJ19 (NEJ60), NESJ29 (NEJ70), NESJ50 (NEJ50), NESJ69, NESJ79, NFSJ25 (NFJ70), NFSJ54 (NFJ54 & NFJ60), NFSJ65 (NFJ62) (see the names in +Annex 2+).

* 21S09 Other OR procedure for injuries – has independent use (for cases without multiple trauma) but is always preceded by rules with 21S03 and 21S04 (and in the new model in MST cases with 21S07) and can thus substituted by the new property 21S10. As always in DRG assignment not all cases with 21S09 follow the rules with 21S09 – preceding rules must be checked. [[http://www.norddrg.net/norddrgmanual/NordDRG_2012_FIN/Flow/PRO_21S09.htm]]

* 21S10 OR procedure for trauma – property given to all interventions that currently have 21S03, 21S04, 21S05 or 21S09. (Includes even codes with 21S07)

In summary, the five procedure properties in new grouper are as follows: 21S03, 21S04, 21S05, 21S07, 21S10.

3. +The analysis of current DRGs+

The aim was to figure out new groups based on clinical meaningfulness and resource homogeneity.

*Suggestion*

The prerequisite that a case is assigned to any DRG in MDC24 is that principal diagnosis has PDGPRO 24P01 ‘Multitrauma dx’. That diagnosis belongs to one of the components of multitrauma i.e. has one of the multitrauma diagnosis properties (24X11, 24X21, 24X22, 24X31, 24X40, 24X41 and 24X61). In addition one of the secondary diagnoses has to belong another multitrauma component.

Based on the analysis we suggest following DRG in MDC24.

The new (remaining) DRG’s (#7) are following:

1) *484N* – Multiple multitrauma with brain injury and OR procedure for trauma

Principal dx is a trauma dx (with principal diagnosis property 24P01)

and

Main or secondary diagnosis has diagnosis property 24X11 (S06.1, S06.2, S06.3, S06.7, S06.8 and S06.9)

and

Another diagnosis has diagnosis property (24X21, 24X22, 24X31, 24X41 or 24X61)

and

any significant MST procedure (new 21S10)

*The difference to current DRG 484 is that the cases are limited to those with brain injury but the intervention may be any MST intervention.*

2) *486A* – Multiple trauma with fracture of lumbar spine and lumbar, pelvic or femur fracture procedure

Principal dx is a multitrauma dx (with principal diagnosis property 24P01)

and

Main or secondary diagnosis has diagnosis property 24X41 Fracture, dislocation or sprain of lumbar spine

and

Another diagnosis has diagnosis property (24X11 ,24X21, 24X22, 24X31 or 24X61)

and

Lumbar, pelvic or femur fracture procedure (21S07)

*This is a new intervention group specific to lumbar spine problems.*

3) *486B* – Thorax and abdomen multiple trauma with OR procedure for trauma

Principal dx is a trauma dx (with principal diagnosis property 00P21)

and

Main or secondary diagnosis of Thorax major injury except spine (24X21)

and

Main or secondary diagnosis has diagnosis property 24X31 `Intra-abdominal major trauma´

and

any MST procedure (new 21S10)

*Surgical Surgical group for combined abdomino-thoracal injuries.* injuries.

4) *486N* – Other multiple trauma with OR procedure for trauma

Principal dx is a multitrauma dx (with principal diagnosis property 24P01)

and

At least one of the secondary dx has to belong to another multitrauma component than principal dx (i.e. two different diagnosis properties from 24X11 ,24X21, 24X22, 24X31, 24X41 and 24X61 have to be represented among the dx)

and

any MST procedure (new 21S10)

*Similar Similar to current DRG 486.* 486.

5) *487N* – as current DRG 487 (Other multiple significant trauma, w/o significant procedure)

Principal dx is a trauma dx (with principal diagnosis property 00P21)

and

At least one of the secondary dx has to belong to another multitrauma component than principal dx. (I.e. two different diangnosis properties from 24X11, 24X21, 24X22, 24X31, 24X41 and 24X61 have to be represented among the dx)

and

No OR-procedure performed

*All All cases of multiple trauma with short therapy and craniotomy (21S04) will be assigned to DRG 003O as before.* before

6) *924O* – as current DRG 924O (Multiple significant trauma, short therapy w/o significant procedure)

7) *824O* – as current DRG 824O (Multiple significant trauma, short therapy w minor intervention)

All cases of multiple trauma with short therapy and any major trauma intervention (21S10 except 21S04) will be assigned to DRG 468O (this regarded as an impossible combination)

*Cost data*

Will be added after test grouping

*Summary*

Will be added at the end.

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