Reconciling hospital-acquired complications and CHADx+ in Victorian coded hospital data.

BACKGROUND: The Council of Australian Governments has focused the attention of health service managers and state health departments on a list of hospital-acquired complications (HACs) proposed as the basis of funding adjustments for poor quality of hospital inpatient care. These were devised for the Australian Commission on Safety and Quality in Health Care as a subset of their earlier classification of hospital-acquired complications (CHADx) and designed to be used by health services to monitor safety performance for their admitted patients. OBJECTIVE: To improve uptake of both classification systems by clarifying their purposes and by reconciling the ICD-10-AM code sets used in HACs and the Victorian revisions to the CHADx system (CHADx+). METHOD: Frequency analysis of individual clinical codes with condition onset flag (COF 1) included in both classification systems using the Victorian Admitted Episodes Dataset for 2014/2015 ( n = 2,623,275 separations). Narrative description of the resulting differences in definition of "adverse events" embodied in the two systems. RESULTS: As expected, a high proportion of ICD-10-AM codes used in the HACs also appear in CHADx+, and given the wider scope of CHADx+, it uses a higher proportion of all COF 1 diagnoses than HACs (82% vs. 10%). This leads to differing estimates of rates of adverse events: 2.12% of cases for HACs and 11.13% for CHADx+. Most CHADx classes (70%) are not covered by the HAC system; discrepancies result from the exclusion from HACs of several major CHADx+ groups and from a narrower definition of detailed HAC classes compared with CHADx+. Case exclusion criteria in HACs (primarily mental health admissions) resulted in a very small proportion of discrepancies (0.13%) between systems. DISCUSSION: Issues of purpose and focus of these two Australian systems, HACs for clinical governance and CHADx+ for local quality improvement, explain many of the differences between them, and their approach to preventability, and risk stratification. CONCLUSION: A clearer delineation between these two systems using routinely coded hospital data will assist funders, clinicians, quality improvement professionals and health information managers to understand discrepancies in case identification between them and support their different information needs.

Dabigatran (Pradaxa) Is Safe for Extended Venous Thromboembolism Prophylaxis After Surgery for Pancreatic Cancer.

BACKGROUND: The American College of Chest Physicians and American Hepato-Pancreato-Biliary Association recommend using low-molecular-weight heparin for 28 days postoperatively for venous thromboembolism prophylaxis after cancer surgery. Dabigatran is a once daily oral anticoagulant that is FDA approved for venous thromboembolism prophylaxis after orthopedic surgery, uses fixed dosing, and has an antidote. METHODS: Patients undergoing surgery for malignant pancreatic tumors (neuroendocrine excluded) from January 2017 to January 2018 were converted to dabigatran 220 mg daily on discharge until postoperative day 28; patients with medical or insurance contraindications were converted to enoxaparin or another direct oral anticoagulant. The primary endpoint was bleeding complications through 90 days. RESULTS: A total of 134 patients were considered for this study (median age 67 ± 10; 58.9% male). Eighty-seven (82.9%) patients received dabigatran and 18 (17.1%) received another form of anticoagulation. There were 19 (4.2%) patients not prescribed dabigatran due to medical or inpatient contraindications. Four patients experienced bleeding complications after discharge while on dabigatran. Two (2%) were major bleeds (Clavien-Dindo IV and V), and 2 (2%) were minor (Clavien-Dindo I). Patient compliance was excellent, with 93% of prescribed patients fully completing their prophylaxis. There were 2 patients that developed symptomatic deep vein thrombosis. CONCLUSION: The use of a direct oral anticoagulant as extended venous thromboembolism prophylaxis after major gastrointestinal surgery has not been studied to date. These results show dabigatran to be a safe alternative to low-molecular-weight heparin for extended venous thromboembolism prophylaxis with regard to bleeding complications.

Emergency and urgent care systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing organization, payment and reforms.

INTRODUCTION: Increasing numbers of hospital emergency department (ED) visits pose a challenge to health systems in many countries. This paper aims to examine emergency and urgent care systems, in six countries and to identify reform trends in response to current challenges. METHODS: Based on a literature review, six countries - Australia, Denmark, England, France, Germany and the Netherlands - were selected for analysis. Information was collected using a standardized questionnaire that was completed by national experts. These experts reviewed relevant policy documents and provided information on (1) the organization and planning of emergency and urgent care, (2) payment systems for EDs and urgent primary care providers, and (3) reform initiatives. RESULTS: In the six countries four main reform approaches could be identified: (a) extending the availability of urgent primary care, (b) concentrating and centralizing the provision of urgent primary care, (c) improving coordination between urgent primary care and emergency care, and (d) concentrating emergency care provision at fewer institutions. The design of payment systems for urgent primary care and for emergency care is often aligned to support these reforms. CONCLUSION: Better guidance of patients and a reconfiguration of emergency and urgent care are the most important measures taken to address the current challenges. Nationwide planning of all emergency care providers, closely coordinated reforms and informing patients can support future reforms.

Health care costs associated with hospital acquired complications in patients with chronic kidney disease.

BACKGROUND: Patients with CKD are at increased risk of potentially preventable hospital acquired complications (HACs). Understanding the economic consequences of preventable HACs, may define the scope and investment of initiatives aimed at prevention. METHODS: Adult patients hospitalized from April, 2003 to March, 2008 in Alberta, Canada comprised the study cohort. Healthcare costs were determined and categorized into 'index hospitalization' including hospital cost and in-hospital physician claims, and 'post discharge' including ambulatory care cost, physician claims, and readmission costs from discharge to 90 days. Multivariable regression was used to estimate the incremental healthcare costs associated with potentially preventable HACs. RESULTS: In fully adjusted models, the median incremental index hospitalization cost was CAN-$6169 (95% CI; 6003-6336) in CKD patients with ≥1 potentially preventable HACs, compared with those without. Post-discharge incremental costs were 1471(95% CI; 844-2099) in those patients with CKD who developed potentially preventable HACs within 90 days after discharge compared with patients without potentially preventable HACs. Additionally, the incremental costs associated with ≥1 potentially preventable HACs within 90 days from admission in patients with CKD were $7522 (95% CI; 7219-7824). A graded relation of the incremental costs was noted with the increasing number of complications. In patients without CKD but with ≥1 preventable HACs incremental costs within 90 days from hospital admission was $6688 (95% CI: 6612-6723). CONCLUSIONS: Potentially preventable HACs are associated with substantial increases in healthcare costs in people with CKD. Investment in implementing targeted strategies to reduce HACs may have a significant benefit for patient and health system outcomes.

Adverse Outcomes Associated with Preventable Complications in Hospitalized Patients with CKD.

BACKGROUND: and objectives Patients with CKD are at risk of hospital-acquired complications (HACs). We sought to determine the association of preventable HACs with mortality, length of stay (LOS), and readmission. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All adults hospitalized from April of 2003 to March of 2008 in Alberta were characterized by kidney function and occurrence of preventable HACs. CKD was defined by eGFR<60 ml/min per 1.73 m2 and/or albumin-to-creatinine ratio >3-30 mg/mmol for >3 months in the time frame from 365 to 90 days before admission. Regression models examined the association of HACs with outcomes. RESULTS: Of 536,549 hospitalizations, 8.5% (n=45,733) had CKD and 9.8% of patients with CKD had one or more potentially preventable HAC. In patients with potentially preventable HACs, proportions of death within index hospitalization and from discharge to 90 days were 17.7% and 6.8%, respectively. In patients with CKD, comparing with those hospitalizations without potentially preventable HACs, the adjusted odds ratio (OR) of mortality during index hospitalization and from hospital discharge to 90 days in patients with one or more preventable HAC was 4.67 (95% confidence interval [95% CI], 4.17 to 5.22) and 1.08 (95% CI, 0.94 to 1.25), respectively. Median incremental LOS in patients with one or more preventable HAC was 9.86 days (95% CI, 9.25 to 10.48). The OR for readmission with preventable HAC was 1.24 (95% CI, 1.15 to 1.34). In a cohort with and without CKD, the adjusted ORs of mortality during index hospitalization in patients with CKD and no preventable HACs, patients without CKD and with preventable HACs, and patients with CKD and preventable HACs were 2.22 (95% CI, 1.69 to 2.94), 5.26 (95% CI, 4.98 to 5.55), and 9.56 (95% CI, 7.23 to 12.56), respectively (referenced to patients without CKD or preventable HACs). CONCLUSIONS: Preventable HACs are associated with higher mortality, incremental LOS, and greater risk of readmission, especially in people with CKD. Targeted strategies to reduce complications should be a high priority.

Risk of Hospital-Acquired Complications in Patients with Chronic Kidney Disease.

BACKGROUND AND OBJECTIVES: Unintended injuries or complications in hospitalized patients are common, potentially preventable, and associated with adverse consequences, including greater mortality and health care costs. Patients with CKD may be at higher risk of hospital-acquired complications (HACs). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Adults from a population-based cohort (Alberta Kidney Disease Network) who were hospitalized from April 1, 2003, to March 31, 2008, made up the study cohort. Kidney function was defined using outpatient eGFR and proteinuria (protein-to-creatinine ratio or dipstick) in the year before index hospitalization. Comorbid conditions were identified using validated algorithms applied to administrative data. A specific diagnostic indicator was used to identify HACs. Complications were classified into clinically homogeneous groups and subclassified as potentially preventable (p-HACs) or always preventable (a-HACs). Multivariable logistic regressions models were used to examine the association of CKD with HACs, accounting for confounders. RESULTS: Of 536,549 patients, 8.5% had CKD; those with CKD were older and more likely to be admitted for circulatory system diseases than those without CKD. In fully adjusted models, the odds ratio (OR) of any hospital complication in patients with CKD (reference: no CKD) was 1.19 (95% confidence interval [95% CI], 1.18 to 1.26); there was a graded relation between the risk of HACs and CKD severity, with an OR of 1.81 (95% CI, 1.51 to 2.17) in those with the most severe CKD (eGFR, 15-29 ml/min per 1.73 m(2) and proteinuria, >30 mg/mmol). Findings were similar for p-HACs (OR, 1.20 [95% CI, 1.16 to 1.24] and 1.78 [95% CI, 1.43 to 2.11], respectively). The a-HACs had similar point estimates. CONCLUSIONS: The presence of CKD and its severity are associated with a higher risk of HACs, including those considered preventable. Targeted strategies to reduce complications in patients with CKD admitted to the hospital should be considered.

Australian diagnosis related groups: Drivers of complexity adjustment.

BACKGROUND: In undertaking a major revision to the Australian Refined Diagnosis Related Group (ARDRG) classification, we set out to contrast Australia's approach to using data on additional (not principal) diagnoses with major international approaches in splitting base or Adjacent Diagnosis Related Groups (ADRGs). METHODS: Comparative policy analysis/narrative review of peer-reviewed and grey literature on international approaches to use of additional (secondary) diagnoses in the development of Australian and international DRG systems. ANALYSIS: European and US approaches to characterise complexity of inpatient care are well-documented, providing useful points of comparison with Australia's. Australia, with good data sources, has continued to refine its national DRG classification using increasingly sophisticated approaches. Hospital funders in Australia and in other systems are often under pressure from provider groups to expand classifications to reflect clinical complexity. DRG development in most healthcare systems reviewed here reflects four critical factors: these socio-political factors, the quality and depth of the coded data available to characterise the mix of cases in a healthcare system, the size of the underlying population, and the intended scope and use of the classification. Australia's relatively small national population has constrained the size of its DRG classifications, and development has been concentrated on inpatient care in public hospitals. DISCUSSION AND CONCLUSIONS: Development of casemix classifications in health care is driven by both technical and socio-political factors. Use of additional diagnoses to adjust for patient complexity and cost needs to respond to these in each casemix application.

Development and Implementation of ExPLORE Clinical Practice, a Web-accessible Comparative Outcomes Tool for California Hospitals and Physicians.

BACKGROUND: Hospital-based clinicians have little information about the outcomes of their care, much less how those outcomes compare with those of their peers. A variety of care quality indicators have been developed, but comparisons tend to be hospitalwide, and often irrelevant to the practice and patient group of many hospital clinicians. Moreover, information is not enough to transform clinical practice, as the human response to such comparisons is, "I'm doing the best I know how." What is needed is granular, clinically specific feedback with peer-mediated advice about how "positive deviants" achieve better results. OBJECTIVE: This case study reports on the development and implementation of a web-accessible comparative outcomes tool, ExPLORE Clinical Practice, for hospitals and clinicians in California. METHODS: We use iterative development and refinement of web tools to report comparative outcomes; incremental development of suites of procedure-patient outcome pairs specific to particular medical specialty groups; testing and refinement of response time metrics to reduce delays in report generation; and introduction of a comments section for each measure that assists with interpretation and ties results to strategies found to lead to better clinical outcomes. RESULTS: To date, 76 reports, each with 115 to 251 statistically evaluated outcomes, are available electronically to compare individual hospitals in California to statewide outcomes. DISCUSSION AND CONCLUSIONS: ExPLORE Clinical Practice is one of a number of emerging systems that attempt to lever available data to improve patient outcomes. The ExPLORE Clinical Practice system combines a clinical focus on highly specific outcome measures with attention to technical issues such as crafting an intuitive user interface and graphic presentation. This case study illustrates the important advances made in using data to support clinicians to improve care for patients. We see this information as a way to start local conversations about quality improvement, and as a means of generating peer advice for improving patient outcomes.

Socio-economic disadvantage and demographics as factors in stage of colorectal cancer presentation and survival.

BACKGROUND: Colorectal cancer (CRC) is common, and early diagnosis improves outcome. Overseas studies have suggested that low socio-economic status (SES) is related to advanced cancer stage at presentation and reduced survival. The situation in Australia is unclear. This study examines the effect of demographic and SES on CRC stage at presentation and survival in a single tertiary centre. METHODS: Patients undergoing surgical resection for CRC (1 January 2005 to 31 December 2010) were identified, and socio-demographic and histopathological information obtained. Four socio-economic indices using 2006 Australian Census data were assigned by residential postcode. Factors contributing to tumour (T) and American Joint Committee on Cancer (AJCC) stage at presentation and survival were assessed. RESULTS: Five hundred and fifty-seven patients were included. Results did not support a relationship between SES and either advanced stage at presentation or survival. Only one index (economic resources) was related to a more advanced T stage at presentation (P = 0.011); none were related to AJCC stage or survival. No significant relationship was found between an individual's country of birth, language spoken, private insurance or employment status and presenting with a later T or AJCC stage. Age, AJCC and T stage at diagnosis and emergency presentation significantly affected survival on multivariate analysis. CONCLUSION: SES and most demographic factors did not appear to significantly influence CRC stage at presentation and outcome. A focus on obtaining equivalent access to health care both nationally and internationally could prove beneficial in improving outcomes for CRC.

Data quality: not selling ourselves short.

Routinely coded hospital data ('administrative data') have been criticised as invalid and unreliable, without due regard for how Australian data differ from those of other healthcare systems. The skills and education of coders, degree of professional coding supervision, and the existence and rigour of coding audits all strengthen Australian routine hospital data.

Exploring in-hospital adverse drug events using ICD-10 codes.

OBJECTIVE: Adverse drug events (ADEs) during hospital admissions are a widespread problem associated with adverse patient outcomes. The 'external cause' codes in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) provide opportunities for identifying the incidence of ADEs acquired during hospital stays that may assist in targeting interventions to decrease their occurrence. The aim of the present study was to use routine administrative data to identify ADEs acquired during hospital admissions in a suburban healthcare network in Melbourne, Australia. METHODS: Thirty-nine secondary diagnosis fields of hospital discharge data for a 1-year period were reviewed for 'diagnoses not present on admission' and assigned to the Classification of Hospital Acquired Diagnoses (CHADx) subclasses. Discharges with one or more ADE subclass were extracted for retrospective analysis. RESULTS: From 57205 hospital discharges, 7891 discharges (13.8%) had at least one CHADx, and 402 discharges (0.7%) had an ADE recorded. The highest proportion of ADEs was due to administration of analgesics (27%) and systemic antibiotics (23%). Other major contributors were anticoagulation (13%), anaesthesia (9%) and medications with cardiovascular side-effects (9%). CONCLUSION: Hospital data coded in ICD-10 can be used to identify ADEs that occur during hospital stays and also clinical conditions, therapeutic drug classes and treating units where these occur. Using the CHADx algorithm on administrative datasets provides a consistent and economical method for such ADE monitoring.

Building the 'continuous learning' healthcare system.

Hospitals are data-rich but information-poor. To develop a 'continuous-learning health care system' we need to harness our myriad information sources so that every patient encounter becomes the basis for new evidence of what works.

Oxygen isotope exchange with quartz during pyrolysis of silver sulfate and silver nitrate.

RATIONALE: Triple oxygen isotopes of sulfate and nitrate are useful metrics for the chemistry of their formation. Existing measurement methods, however, do not account for oxygen atom exchange with quartz during the thermal decomposition of sulfate. We present evidence for oxygen atom exchange, a simple modification to prevent exchange, and a correction for previous measurements. METHODS: Silver sulfates and silver nitrates with excess (17)O were thermally decomposed in quartz and gold (for sulfate) and quartz and silver (for nitrate) sample containers to O(2) and byproducts in a modified Temperature Conversion/Elemental Analyzer (TC/EA). Helium carries O(2) through purification for isotope-ratio analysis of the three isotopes of oxygen in a Finnigan MAT253 isotope ratio mass spectrometer. RESULTS: The Δ(17)O results show clear oxygen atom exchange from non-zero (17)O-excess reference materials to zero (17)O-excess quartz cup sample containers. Quartz sample containers lower the Δ(17)O values of designer sulfate reference materials and USGS35 nitrate by 15% relative to gold or silver sample containers for quantities of 2-10 µmol O(2). CONCLUSIONS: Previous Δ(17)O measurements of sulfate that rely on pyrolysis in a quartz cup have been affected by oxygen exchange. These previous results can be corrected using a simple linear equation (Δ(17)O(gold) = Δ(17)O(quartz) * 1.14 + 0.06). Future pyrolysis of silver sulfate should be conducted in gold capsules or corrected to data obtained from gold capsules to avoid obtaining oxygen isotope exchange-affected data.

Adverse event rates as measures of hospital performance.

OBJECTIVES: Adverse event or complication rates are increasingly advocated as measures of hospital quality and performance. Objective of this study is to analyse patient-complexity adjusted adverse events rates to compare the performance of hospitals in Victoria, Australia. We use a unique hospital dataset that routinely records adverse events which arise during the admission. We identify hospitals with below or above average performance in comparison to their peers, and show for which types of hospitals risk adjusting makes biggest difference. METHODS: We estimate adverse event rates for 87,790 elective and 43,771 emergency episodes in 34 public hospitals over the financial year 2005/06 with a complementary log-log model, using patient level administrative hospital data and controlling for patient complexity with a range of covariates. RESULTS: Teaching hospitals have average risk-adjusted adverse event rates of 24.3% for elective and 19.7% for emergency surgical patients. Suburban and rural hospitals have lower rates of 17.4% and 17%, and 16.1% and 15.7%, respectively. Selected non-teaching hospitals have relatively high rates, in particular hospitals in rural and socially disadvantaged areas. Risk adjustment makes a significant difference to most hospitals. CONCLUSION: We find comparably high adverse events rates for surgical patients in Australian hospitals, possibly because our data allow identification of a larger number of adverse events than data used in previous studies. There are marked variations in adverse event rates across hospitals in Victoria, even after risk adjusting. We discuss how policy makers could improve quality of care in Australian hospitals.

Access with evidence development: an approach to introducing promising new technologies into healthcare.

The rapid development of new health technologies for which there is limited, but promising, evidence has resulted in a daunting challenge - to provide care that meets population health needs and optimizes patient outcomes, demonstrates an efficient use of healthcare resources, and upholds basic principles of equity, access, and choice. In this paper, we introduce 'Access with Evidence Development' as a possible mechanism for addressing this challenge and discuss its application to the "Zamboni procedure" for Multiple Sclerosis.

Comparing the coding of complications in Queensland and Victorian admitted patient data.

OBJECTIVE: To examine differences between Queensland and Victorian coding of hospital-acquired conditions and suggest ways to improve the usefulness of these data in the monitoring of patient safety events. DESIGN: Secondary analysis of admitted patient episode data collected in Queensland and Victoria. METHODS: Comparison of depth of coding, and patterns in the coding of ten commonly coded complications of five elective procedures. RESULTS: Comparison of the mean complication codes assigned per episode revealed Victoria assigns more valid codes than Queensland for all procedures, with the difference between the states being significantly different in all cases. The proportion of the codes flagged as complications was consistently lower for Queensland when comparing 10 common complications for each of the five selected elective procedures. The estimated complication rates for the five procedures showed Victoria to have an apparently higher complication rate than Queensland for 35 of the 50 complications examined. CONCLUSION: Our findings demonstrate that the coding of complications is more comprehensive in Victoria than in Queensland. It is known that inconsistencies exist between states in routine hospital data quality. Comparative use of patient safety indicators should be viewed with caution until standards are improved across Australia. More exploration of data quality issues is needed to identify areas for improvement.

Marginal costs of hospital-acquired conditions: information for priority-setting for patient safety programmes and research.

OBJECTIVE: To estimate the relative inpatient costs of hospital-acquired conditions. METHODS: Patient level costs were estimated using computerized costing systems that log individual utilization of inpatient services and apply sophisticated cost estimates from the hospital's general ledger. Occurrence of hospital-acquired conditions was identified using an Australian 'condition-onset' flag for diagnoses not present on admission. These were grouped to yield a comprehensive set of 144 categories of hospital-acquired conditions to summarize data coded with ICD-10. Standard linear regression techniques were used to identify the independent contribution of hospital-acquired conditions to costs, taking into account the case-mix of a sample of acute inpatients (n = 1,699,997) treated in Australian public hospitals in Victoria (2005/06) and Queensland (2006/07). RESULTS: The most costly types of complications were post-procedure endocrine/metabolic disorders, adding AU$21,827 to the cost of an episode, followed by MRSA (AU$19,881) and enterocolitis due to Clostridium difficile (AU$19,743). Aggregate costs to the system, however, were highest for septicaemia (AU$41.4 million), complications of cardiac and vascular implants other than septicaemia (AU$28.7 million), acute lower respiratory infections, including influenza and pneumonia (AU$27.8 million) and UTI (AU$24.7 million). Hospital-acquired complications are estimated to add 17.3% to treatment costs in this sample. CONCLUSIONS: Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harm. Previous studies of the costs of adverse events have provided information on 'indicators' of safety problems rather than the full range of hospital-acquired conditions. Adding a cost dimension to priority-setting could result in changes to the focus of patient safety programmes and research. Financial information should be combined with information on patient outcomes to allow for cost-utility evaluation of future interventions.

Public hospital admissions for treating complications of clinical care: incidence, costs and funding strategy.

OBJECTIVE: To quantify the frequency of, and the costs and payments associated with, admissions for treatment of injuries and illnesses that are consequences of care. DATA SOURCES: Routinely-coded 2005/06 public hospital inpatient data from Victoria, Australia (1.25 million admissions) and corresponding patient-level cost data (1.04 million admissions). Payments reflected DRG-based prospective rates. STUDY DESIGN: Retrospective analysis of admissions with principal diagnoses that specify adverse events arising as a direct consequence of healthcare. RESULTS: 1.5% (15,336) of the costed admissions specifically treat an injury or illness arising from medical or surgical care, consuming 2.74% of hospital prospective payments and representing $89.3 m (2.84%) of total reported costs. 1.4% (17,429) of all public hospital admissions and 2.82% of hospital prospective payments (estimated cost-$101.5 m per year) are committed to treating complications of care. Private residences or aged care facilities are the source of 84.9% (14,804) of these admissions. Inpatient death was the outcome in 0.7% (118) of these admissions. IMPLICATIONS: Admissions for treating complications of care represent a small, relatively expensive, proportion of hospital admissions, which account for disproportionate levels of hospital costs and funding. A policy option providing incentives to reduce the incidence and costs of complications arising from care includes allocating all costs arising from transferred (re)admissions back to the original episode of care and developing a suite of specific DRGs to fund admissions for treatment of complications.

The US Medicare policy of not reimbursing hospital-acquired conditions: what impact would such a policy have in Victorian hospitals?

OBJECTIVE: To model the effect of excluding payment for eight hospital-acquired conditions (HACs) on hospital payments in Victoria, Australia. DESIGN, SETTING AND PARTICIPANTS: Retrospective ecological study using the Victorian Admitted Episodes Dataset. The analysis involved all acute inpatient admissions to Victorian public and private hospitals between 1 July 2007 and 30 June 2008. INTERVENTIONS: Each admission record includes up to 40 diagnosis and procedure codes from which payments are calculated. The model deleted diagnosis codes for eight HACs from all records, then recalculated payments to estimate the impact of a policy of non-payment for HACs. MAIN OUTCOME MEASURE: The effect on hospital payments of excluding diagnosis codes for eight HACs. RESULTS: 2,047,133 cases with total estimated payments of $4902 million were identified; 994 cases (0.05%) had one or more diagnoses meeting the code definition for a definable HAC, representing total payments of $24.1 million. In-hospital falls and pressure ulcers were the most commonly coded HACs. Applying a model that excluded HAC diagnosis codes changed the diagnosis-related group for 134 cases (13.5%), thereby generating a $448,630 reduction in payments. CONCLUSIONS: Introducing a non-payment for HACs policy similar to that introduced by Medicare in the United States would have little direct financial impact in the Australian context, although additional savings would accrue if HAC rates were reduced. Such a policy could add further incentive to current initiatives aimed at reducing HACs.

The costs and adverse events associated with hospitalization of patients with spinal cord injury in Victoria, Australia.

STUDY DESIGN: Analysis of patient-level diagnostic and cost data from an administrative database. OBJECTIVE: To describe complications and cost differentials for hospitalized patients with traumatic spinal cord injury (T-SCI) and nontraumatic spinal cord injury (NT-SCI). SUMMARY OF BACKGROUND DATA: Numerous studies have reported costs for T-SCI, but few have involved NT-SCI. METHODS: All patients with SCI admitted between June 1, 2003 and June 30, 2004 were identified using coding from the International Classification of Diseases and Related Health Problems 10th edition, Australian modification (ICD-10-AM). Analysis of database from 45 major acute care public hospitals included in the Victorian Cost Weights Study hospitals (n = 1605 episodes with a SCI). Complications were identified using the Victorian Department of Human Services C-prefix, assigned to hospital-acquired ICD-10-AM diagnoses. RESULTS: Most (85.5%) SCI episodes involved NT-SCI. The ratio of acute to chronic admissions was high for T-SCI (1:0.05), but reversed for NT-SCI (1:1.36). Complications were documented in 38% of SCI episodes. T-SCI showed a higher rate of complications (56%) than NT-SCI (35%). SCI admissions with a complication were significantly more costly (mean, $A43,410) compared with those without a complication (mean, $A10,102). Length of stay was extended by an average of 32 days in the presence of a complication. CONCLUSIONS: SCI entails costly hospital care and high risk of hospital-acquired illness. Some of these complications are preventable. Better understanding of the financial costs of these episodes can assist healthcare providers and funders to weigh the benefits of interventions to reduce the rates of complications in these vulnerable patients.