Case #222

Updated by Anonymous about 7 years ago

Last updated: 2009-03-20
Status: CLOSITEM - Closed item
Initiated: 2009-02-03
By: Norway
Expert Network 2009-02-26 - Change recommended
Board 2009-03-20 - Recommendation accepted

*BACKGROUND:*

Age-related macular degeneration (AMD) can be treated by injecting certain drugs into the corpus vitreum of the eye. This treatment is most often given in an outpatient setting, and the procedure itself doesn’t require any operation room facility. During the first eight months of 2008 about 6000 such cases are identified in Norwegian hospital data, and they are all grouped to surgical DRGs. We consider this to be wrong. We therefore propose a change in procedure properties to make the grouping result more meaningful.

*Relevant codes and DRGs*

The most important code in this regard is NCSP CKD05 Injeksjon av medikament i corpus vitreum, which has the following properties:

!2009-MDC02-01_1.jpg!

From a medical perspective the 02S07 property is correct, but the others are wrong. OR property (if any) should be 2. 14S90 and 21S09 should be removed.
In the Norwegian material the H35.3 Degenerasjon av makula og bakre pol is the dominating code used to describe the main condition when CKD05 is performed. The coding of conditions is not a part of the main problem, but one should be aware that H35.3 has DGPROP 02X03 which affects the grouping result for outpatients.
In the Norwegian material the by far most frequent grouping result is DRG 042 (since Norway in 2008 has not implemented NordDRG day surgery DRGs). In the common Nordic version of the DRG system, the grouping result would most frequently be 036O (H35.3) or 042O (other MDC02 code without DGPROP 02X03).

*Other aspects*

The treatment in concern is not photodynamic therapy (PTD). It is the direct drug effect itself that is important, and application of light is not required. +Case 2007-MDC02-01+ [[http://documents.norddrg.net/issues/221]] [[Case 2007-MDC02-01]] deals with some of the same issues that are discussed here, but its focus is somewhat different.

At present at least two different drugs are in use, ranibizumab (Lucentis®) and bevacizumab (Avastin®). Both are administered the same way, and they share important pharmacological properties. The former is far more expensive than the latter: NOK 12.000 vs NOK 800 for each injection. The documentation of bevacizumab for intravitreal use in the treatment of AMD is insufficient and is considered experimental by +The [[The Norwegian Council for Quality Improvement and Priority Setting in Health Care+ [[http://www.kvalitetogprioritering.no/saker/innf%C3%B8ring-av-ny-og-kostbar-teknologi-lucentis-vs.avastin;jsessionid=17FE137BA168FA02B46F01F5007FDFC7]]. Care]].

The fact that different drugs with great variation of costs are in use results in heterogeneity of total cost for the cases in concern. The large volume of such cases within the relevant DRGs is also a problem to the resource homogeneity of theses DRGs. This problem will not be solved by a change of grouping logic on its own. In fact, this and other problems concerning differences in costs for different drugs can only be solved by giving different drugs specific properties for specific conditions in the grouping logic. This would require a far more complex DRG model than the present one, and is by now not preferable.

Instead, variance of costs due to different drugs in use must to some degree be tolerated, and calculation of cost weights must take such variation into account. Alternately certain drug costs could be unbundled from the cost analysis, and the reimbursement model in in each country could be adjusted accordingly.

Even if there are many ways of dealing with the challenges that drug therapy rises, the grouping result must be medically meaningful. The core question is whether or not an “injection into the corpus vitreum of the eye” is to be considered an OR1 procedure. We find the answer is no.

*Proposal*

Properties of the code CKD05 Injeksjon av medikament i corpus vitreum are changed to

!2009-MDC02-01_2.jpg!

This will cause grouping of cases to non-surgical and mostly outpatient DRGs, for which the DRG solutions by now vary across the countries. A common solution could be to implement a short stay DRG for ‘special medical treatment of eyes or vision’ (or something similar).

*COMMENTS*

*Expert Network 2009-02-26*

The meeting recommended that the procedure CKD05 should have OR2 and delete the proc.prop 02S07.
For Sweden also some speciell swedish property so this DRG will go to “öppenvårdsdrg”. Mats Fernström will provide the Swedish property.

*Supplement Mats Fernström 2009-03-25*

The Swedish procedure property should be 02V02, leading to DRG 760O “Läkemedelstillförsel i ögonregionen, besök”.

*CHANGES:*

*Technical changes:*

For CKSD05 OR property is changed to 2 and all procedure properties are removed. .
CKSD05 is given procedure properties 02O05 ‘Medication to eye’ and 02V02 ‘Medication to eye’.

*DRG changes:*

Cases with CKSD05 are not assigned to surgical DRG’s 042X or 036O . As inpatients the cases are assigned to conservative DRG’s, As outpatients the cases are assigned to DRG 802O ‘Non-extensive procedure of eye, short therapy’ in common NordDRG and to DRG 802NT ‘Medication to eye, short therapy’ in NordDRG Nor and to DRG 760V ‘Medication to eye, short therapy’ in NordDRG Swe.

*Introduction:*

2010

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