The DRG hospital payment system, surgical readmissions and cost containment.

We analyzed all adult surgical patients requiring readmission to the surgical service of an acute care academic hospital for a four-year period (1/1/85-12/31/88). We stratified surgical readmissions by the number of times the patient was readmitted to surgery (from one to five times). For surgical patients 41.1 per cent of the readmission population was readmitted more than once, only 4.4 per cent were readmitted five or more times. Patients requiring three or more admissions generally had the greatest hospital resource utilization, financial risk under DRG payment, and mortality, compared with other surgical readmissions. This analysis suggests that within the surgical readmission population resource parameters may differ by the number of readmissions per patient. Factors were identified which corresponded to a greater likelihood of surgical readmission, and possibly allow the focus of outpatient services which may reduce hospital inpatient costs in the future.

Economies of scale, physician volume for urology patients, and DRG prospective hospital payment system.

Diagnosis Related Group (DRG) hospital payment has begun to squeeze hospitals financially and is likely to do so in the future. This study analyzed the relationship between the volume of urologic procedures by an individual urologist, hospital costs per patient, and outcome. We used a three-year DRG database of urology patients (N = 2,980) at an academic medical center to analyze these. Low-volume urologists (arbitrarily defined by us) had higher hospital costs per patient, financial losses versus profits under DRGs, and a poorer outcome when compared with high-volume urologists. Pearson correlation showed a positive relationship between cost per patient and physician volume for nonemergency patients (-0.129, p less than 0.0001) and emergency patients (-0.368, p less than 0.0001). This may have been explained (in part) by a greater severity of illness for patients of low-volume urologists. These findings suggest, however, that the volume of urologic procedures per urologist may be related to hospital resource consumption. The health care financing environment of the future should provide substantial interest in this finding for those involved in the consumption of urologic services.

Hospital readmissions, otolaryngology, and the diagnosis related group hospital payment system.

An analysis of otolaryngologic patients requiring readmission was conducted at our institution during a 4-year period to determine the number of readmissions per patient and the time between discharge and hospital readmission. Readmitted otolaryngologic patients were found to have had greater hospital resource utilization, financial risk under diagnosis-related group payment, and mortality, compared with those patients not readmitted to our facility. For patients readmitted to otolaryngologic services (21.2% of total otolaryngologic patients), 20.4% of the readmissions occurred within 30 days of hospital discharge. Of these, 39.3% required one hospital readmission, 16.3% required two readmissions, and 46.4% of the patients called for three or more hospital admissions. Clinical factors were identified that resulted in a greater incidence of otolaryngologic readmission. Otolaryngologic patients readmitted to other clinical services were also studied. This analysis loads to the conclusion that inequities exist within the diagnosis related group hospital payment system vis-à-vis otolaryngologic readmissions. The results of these data also demonstrate leverage points in which we will be able to focus outpatient services for otolaryngologic patients requiring readmission and potentially decrease inpatient hospital expenditures in the days ahead.

Economies of scale, physician volume for orthopedic surgical patients, and the DRG prospective payment system.

American hospitals face increasing constraints due to a variety of factors. Federal and state diagnostic-related group (DRG) prospective hospital pricing has caused tremendous fiscal pressure on hospitals; many face substantial financial deficits. We analyzed the volume of orthopedic surgical procedures performed by an individual orthopedic surgeon for all patients (N = 2,134) treated for a 3-year period at a large academic medical center; these surgeons were arbitrarily divided into low volume or high volume. Patients of low volume surgeons had a longer hospital length of stay and hospital cost (after correction for DRG case mix and severity of illness), greater financial risk under DRGs, and a poorer outcome, compared with patients of higher volume orthopedic surgeons. Pearson correlation showed an inverse relationship between cost per patient and physician volume for nonemergency patients -0.201 (P less than .0001), and emergency patients, -0.321 (P less than .0001). Although the reasons for these findings appeared multifactoral, they raise important issues related to orthopedic surgical hospital costs, access, and quality of care. In addition, they suggest that hospital cost for these patients (and perhaps outcome) may be related to orthopedic surgical volume, and that DRG hospital payment (on the margin) may affect future orthopedic surgical practice opportunities.