Case #179

Updated by Anonymous over 5 years ago

Initiated (date):4.11.2013
Initiator: National DRG Centre in Finland / Kristiina Kahur, Minna-Liisa Sjöblom
Responsible at NPK: Kristiina Kahur, Minna-Liisa Sjöblom

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*Problem*

Finnish national DRG-centre 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 analysis the data of 5 university hospitals of Finland from year 2012 was used.
For grouping the test grouper was created by Nordic Casemix Center. Test grouper was updated twice as the intermediate versions didn’t give expected results.

For comparison the results of grouping with Finnish 2014 Full version grouper 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 starting with first letter S from ICD-10 Chapter XIX (Injury, poisoning and certain other consequences of external causes) (S00-T98) are coded.

During the revision process the following steps were taken:

1. +*Revision of diagnosis lists used for MST grouping logic*+

The NordDRG grouping MST 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 MST (with dgprop 24X90). This model is represented in the NordDRG manual.
The analysis with Finish national data revealed that not all combinations are resource intensive. The dx for MST (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 MST. All current diagnosis properties for components of MST (24X..) except 24X40 will be inactivated.

a) Severe intracranial trauma S06.1-3, S06.7-9 (*Dgprop 24X11*)
b) Thorax major injury except spine S22 – S29 (excl S22.0 and S22.1, S23.0 and S23.3) (*Dgprop 24X21*)
c) Fracture or sprain of thoracic spine S22.0, S22.1, S23.0 and S23.3 (*Dgprop 24X22*)
d) Intra-abdominal major trauma S35-S39 (excl S37, S38.0 and S38.2) (*Dgprop 24X31*)
e) Fracture, dislocation or sprain of lumbar spine S32.0, S32.1, S33.0, S33.1 ja S33.5 (*Dgprop 24X41*)
f) Significant kidney trauma S37.0 (*Dgprop 24X40* – existing property)
g) Pelvic major trauma except spinal S32-S34 (excl S32.0 and S32.1; S33.0, S33.1 and S33.5 - incl. sacrum) (*Dgprop 24X61*)

No diagnosis will be assigned to MDC24 alone. The dx now belonging to dx category 24M99 will belong to dx 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 multiple significant trauma (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:

a) +21S03+ Hand procedure for injuries – has independent use in the cases without multiple trauma and must be retained for those purposes
b) +21S04+ Craniotomy for trauma – has independent use both in the cases with and without multiple trauma and must be retained for those purposes
c) +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.
d) 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+).

e) +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.
f) 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 analyse clinical meaningfulness and resource homogeneity of current DRGs (grouped with Finnish 2014 Full version grouper), compare them to grouping results with test grouper and come up with suggestions for new/modified DRGs.

*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.

The special attention was paid to conservative multitrauma cases (DRG 487) and short therapy multitrauma cases (824O, 924O and 468O). After the first update of test grouper it was clear that the resource homogeneity in these DRGs doesn’t improve and it was decided that DRGs 487, 824O, 924O and 468O will be excluded from MDC24 and the cases will be assigned to any other DRG according to coded diagnoses, procedures and any relevant information needed for grouping.

It means that new MDC24 will include only DRGs of MST cases *with* significant surgical procedure(s).

Based on the analysis we suggest following new DRGs (# 4) in MDC24

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

Principal dx is a multitrauma dx (with principal diagnosis property 24P01)
plus
Main or secondary diagnosis has diagnosis property 24X11 (S06.1, S06.2, S06.3, S06.7, S06.8 and S06.9)
plus
Another diagnosis has diagnosis property 24X21, 24X22, 24X31, 24X41 or 24X61.
plus
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)
plus
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)
plus
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 multitrauma dx (with principal diagnosis property 24P01)
plus
Main or secondary diagnosis has diagnosis property 24X21 ‘Thorax major injury except spine’
plus
Main or secondary diagnosis has diagnosis property 24X31 ‘Intra-abdominal major trauma’
plus
any MST procedure (new 21S10)

Surgical group for combined abdomino-thoracal injuries.

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

Principal dx is a multitrauma dx (with principal diagnosis property 24P01)
plus
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)
plus
any MST procedure (new 21S10)

Similar to current DRG 486.

5) +Inactivated DRG’s+

Current DRG 485 ‘Limb reattachment, hip and femur proc for multiple signific trauma’ and current DRG 487 ‘Other multiple significant trauma’ as well as all short therapy groups 486O ‘Other o. r. procedures for multiple significant trauma, short therapy’, 824O ‘Non-extensive procedure for multiple trauma, short therapy’ and 924O ‘Multiple significant trauma, short therapy w/o significant procedure’ will be inactivated.
The number of multiple trauma cases in total will be diminished and the cases will be assigned based on the MDC of the principal dx.
Cases in DRG 485 will be mostly assigned to DRG’s based on the principal dx MDC since the limb dx’s are no more included in the components of multiple trauma. If the cases still fulfil the criteria on multiple trauma, they will most probably be assigned to DRG 486N.
All earlier multiple trauma cases without significant interventions (487) will be assigned to DRG’s based on the principal dx MDC and dgcat.
All short therapy cases will be assigned to DRG’s based on the principal dx MDC and dgcat. Changes of DRG 824O and 924O will only affect those versions that use these groups. Otherwise the existing outpatient rules will take precedence.

*Cost data*

Cost data are presented as comparison between current Finnish 2014 Full version grouper and test grouper even though there is no exact accordance between DRGs of these two grouper.
From analyses the inpatient cases less than 1000€ and outpatient cases less than 300EUR were excluded.

*Current grouper:*

!2014-MDC24_1.jpg!

*Test grouper:*

!2014-MDC24_2.jpg!

Weighted average of V% for the surgical groups (484, 485, 486 to 484N, 486A, 486B, 486N) diminishes from 85% to 78%. The number of cases in these groups diminishes from 160 to 131. The mean cost of the 29 cases reassigned to other MDC’s is 34’759€.
487N is the hypothetical group that would be formed if the new components would be applied to cases without significant interventions. As can be seen this is not a very resource intensive group. The modified group would have a higher V% than the existing 487 and thus it is not at all motivated. The cost level is similar to the DRG’s where these cases would be assigned without this DRG (and the rules for multiple trauma), see below. Therefore it is suggested, that DRG 487 is deleted altogether.

*Effect on other DRG’s*

Cost data of those DRGs into which the cases of current DRG 487 (Other multiple significant trauma, w/o significant procedure) are reassigned to see the impact of new logic to other than MDC24 DRGs.

56% of the cases currently assigned to DRG 487 were assigned to 4 DRGs:

027 – Severe traumatic brain injury
236 – Fractures of hip & pelvis
205 – Disorders of liver except malig, cirr, alc hepa w cc
101 – Other respiratory system diagnoses w cc
The # of cases in other DRGs was rather small and hence the impact on cost data not remarkable.

The cost data of these 4 DRGs without and with additional cases are as follows:

*Current grouper (without additional cases)*

!2014-MDC24_3.jpg!

*Test grouper (with additional cases)*

!2014-MDC24_4.jpg!

The number of surgical inpatient cases reassigned to other MDC’s is rather low (29) and will probably not have any major effect on any DRG although the mean cost is high (34’759 €). As a matter fact the most expensive case of the data (145’010€ in current DRG 385) belongs to this group and makes 14.4% of the group.

Removing the cases of short therapy DRGs 824O and 924O to other DRGs had minimum influence as the # of cases in DRG where the MST cases were reassigned was relatively high compared to # of additional cases.
As for DRG 486O, there were only 11 cases grouped with current grouper and the impact of regrouping of these cases to another DRGs was non-remarkable.

*Suggestion*

Based on analysis of cost data we suggest considering as MST patients only those whom significant surgical procedures have performed. Those without surgery (conservative and short therapy cases) will be excluded from current MDC24.

As a result we suggest to have 4 DRGs in MDC24, all surgical ones, as follows:

*484N* – Multiple trauma with brain injury and OR procedure for trauma
*486A* – Multiple trauma with fracture of lumbar spine and lumbar, pelvic or femur fracture procedure
*486B* – Thorax and abdomen multiple trauma with OR procedure for trauma
*486N* – Other multiple trauma with OR procedure for trauma

Current conservative and short therapy DRGs will be excluded from MDC24 and the cases will be assigned to other DRGs.

The remaining DRG’s for multiple trauma have lower V% than current. Although the number of cases in DRG’s 484N, 486A and 486B would be fairly low, they are separate clinical entities and therefore can be motivated.

Since MDC 24 would not any more include any conservative cases, it is questionable whether it any more composes a MDC. Rather the cases are a group of trauma cases. Therefore we suggest that MDC 24 is inactivated and the new DRG’s are assigned to MDC 21.

*Comment Expert Group 2014-03-24*

Suggestion looks good but grouping logic should be done simple. Coding practice could be different in different countries. To test this there is need for definition tables and all countries can do own analysis based on the new rules.
Batch grouper based on definition tables will be delivered to Norway.
Definition tables are delivered to Sweden.

But much work left to be done. Not possible to do it for 2015. The case will be postponed except for Finland.

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