On the use of administrative databases to support planning activities: the case of the evaluation of neonatal case-mix in the Emilia-Romagna region using DRG and APR-DRG classification systems.

There are several versions of the Diagnosis Related Group (DRG) classification systems that are used for case-mix analysis, utilization review, prospective payment, and planning applications. The objective of this study was to assess the adequacy of two of these DRG systems--Medicare DRG and All Patient Refined DRG--to classify neonatal patients. The first part of the paper contains a descriptive analysis that outlines the major differences between the two systems in terms of classification logic and variables used in the assignment process. The second part examines the statistical performance of each system on the basis of the administrative data collected in all public hospitals of the Emilia-Romagna region relating to neonates discharged in 1997 and 1998. The Medicare DRG are less developed in terms of classification structure and yield a poorer statistical performance in terms of reduction in variance for length of stay. This is important because, for specific areas, a more refined system can prove useful at regional level to remove systematic biases in the measurement of case-mix due to the structural characteristics of the Medicare DRGs classification system.

Funding and future diagnosis related group development.

PURPOSE: Diagnosis Related Groups (DRGs) are widely used for a variety of purposes including quality improvement, hospital output measurement and funding. DRGs are a patient classification scheme which provides a means of relating the type of patients a hospital treats (i.e., its casemix) to the costs incurred by the hospital. This is done by classifying patients into mutually exclusive groups based on the patient's principal diagnosis and other information. The original Health Care Financing Administration DRGs (HCFA DRGs) have been in use since 1982. This document provides an overview of future directions for the newer DRG systems and it provides a framework for understanding the use of DRGs for funding. FUTURE DIRECTIONS: Newer DRG systems incorporate explicit adjustment for severity of illness, include separate measures for the likelihood of mortality, and are more independent of the underlying coding systems (e.g., ICD-10 for diagnoses, ICD-9-CM for procedures). THE FRAMEWORK: The framework for a casemix-based budgeting system consists of five basic aspects. They are: 1) Categories--which kind of DRG will be the basis for the casemix system; 2) Relative Weights--relative weights reflect the expected cost of a case in one DRG relative to the expected cost of the average patient; 3) Base Rates/Pricing--the base rate converts the relative values to prices or budgets; 4) Adjustments--adjustments account for exogenous factors; 5) Transition Policy--this provides time so hospital administrators can learn to respond to the incentives contained in the DRG system.

Unanticipated plasma concentrations in two clozapine-treated patients.

OBJECTIVE: To report two cases of lower than anticipated clozapine plasma concentrations despite near maximum recommended doses of clozapine 800-900 mg/d in two medication-compliant schizophrenic inpatients. CASE SUMMARIES: Clozapine therapy was initiated in two male schizophrenic inpatients for treatment of psychotic symptoms refractory to other typical and atypical antipsychotics. Despite receiving adequate doses of clozapine for at least two months, these patients remained symptomatic. Therapeutic drug monitoring was used to target a clozapine plasma concentration of > or =250 ng/mL, the minimum value reported in the literature to be associated with increased clinical response. Clozapine plasma concentrations remained at 200 ng/mL in one patient despite dosage increases from 600 to 800 mg/d. In the second patient, administration of the maximum recommended dose resulted in concentrations between 200 and 250 ng/mL. Increasing the clozapine dosage to 1000 mg/d did not increase the clozapine plasma concentration. Evaluation of the ratio of clozapine plasma concentration clozapine to dose yielded lower than expected values compared with those reported in the literature. DISCUSSION: These two patients exhibited lower than anticipated clozapine plasma concentrations despite receiving high doses of clozapine. Several studies evaluating clozapine serum concentrations and clinical response have suggested threshold concentrations of > or =350 ng/mL, > or =370 ng/mL, or > or =420 ng/mL. The only study that randomized patients to three concentration ranges found that patients who achieved a clozapine serum concentration in a medium range (mean 251 ng/mL) responded better than patients in a low range (mean 91 ng/mL) and similar to patients in a high range (mean 396 ng/mL). However, attaining plasma concentrations in this range for these patients proved difficult. Reasons for the low concentrations are unclear and may be related to increased metabolic activity at several cytochrome P450 isoenzymes involved in the metabolism of clozapine. CONCLUSIONS: These cases illustrate lower than anticipated clozapine plasma concentrations despite high-dose clozapine therapy. Strategies to increase clozapine plasma concentrations in such patients might include adding a drug to partially inhibit the metabolism of clozapine. If those strategies are unacceptable based on risk assessment, patient compliance, or other reasons, clinicians may consider addition of a low-dose typical or other atypical antipsychotic drug to augment clozapine response.

Prior and current costs in capitated health plans: the effects of health status at enrollment.

We compared the prior and current costs of persons age 65 and older enrolling in a Social/Health Maintenance Organization in each of four sites with samples of persons using standard Medicare benefits in each site. Analyses were adjusted for individual health differences using case mix scores. Costs were examined in the year before S/HMO enrollment or prior to the sampling of a person using regular Medicare services as well as costs during the study. Costs during the study are analyzed using a two-stage procedure where first the propensity to enroll in a S/HMO is modeled and then costs derived from either Medicare sources or shadow prices assigned to service units provided in a S/HMO are modeled. The costs for case mix groups with different health and functional characteristics varied significantly. Cost differences between case mix classes differed between the S/HMO and FFS populations.

Achieving short-term Medicare savings through the expansion of the prospective payment system.

This article addresses the introduction of competition into the Medicare prospective payment system (PPS), the application of aa expanded PPS to ensure that Medicare is not paying more than the market price for comparable services, the expansion of the Medicare PPS to outpatient services, and the expansion of the Medicare PPS to physician fees for inpatient care.

Evaluating long-term care demonstrations in real time with study design and plan performance interactions.

The evaluation of long-term care demonstrations has to deal with complex organizational entities, with large, heterogeneous client populations that, during the course of study, may have to change features of their organization or operation. The implications of such "real-time" changes are discussed for analyses of the operation and performance of Social/Health Maintenance Organizations over a 5-year period (2 years of start-up and enrollment and 3 years of follow-up). Analyses conducted of the plans in the context of real-time changes have to be based on different statistical models than for classic experimental study designs, where treatment factors are fixed rather than dynamic. A number of issues that may arise are identified, and possible approaches to their solutions described. Key words: long-term care; demonstrations; evaluations; study design; capitation.

Case mix controlled service use and expenditures in the social/health maintenance organization demonstration.

BACKGROUND: The social health maintenance organization (S/HMO) demonstration was implemented, in part, to determine if the presumed integration of acute and chronic care in these plans could produce sufficient savings to allow plans to offer expanded and chronic care benefits without increased cost to the Medicare program. METHODS: S/HMO members and a sample of fee-for-service (FFS) recipients were tracked over three years to assess their utilization experience. Analyses controlled for case mix, using Grade of Membership procedures. RESULTS: In 1987, the last year of risk sharing, S/HMOs reported higher total expenditures than FFS in each health status class. For the "healthy," differences were largest for physician care. In other classes, differences in nonskilled nursing or home care use were noted. In 1988, the first year of full risk, Seniors Plus had equivalent or lower expenditures relative to FFS for all classes. Elderplan had lower expenditures in four of six classes and provided more service to the "frail" and the "acutely ill." SHP had higher expenditures in all classes because of higher hospital and nursing home expenditures. Medicare Plus II had higher expenditures in all classes, for physician, nonskilled nursing home, and home care expenditures. CONCLUSIONS: Overall plan losses and higher expenditures among a number of case mix groups suggest a need for refinement of S/HMO operations--especially in case management relationships to medical care and in the selection of "high risk" cases.

Developing an outpatient prospective payment system based on APGs for the Iowa Medicaid program.

This article describes the development of an outpatient prospective payment system (PPS) based on ambulatory patient groups (APGs) for the Iowa Medicaid Program. Currently, hospitals in Iowa are reimbursed for outpatient services on the basis of cost. Because of concern about escalating costs, the Iowa General Assembly mandated development of a hospital outpatient payment system to promote efficient use of resources and high quality care. The first use of APGs for payment across the full spectrum of services will be a testing ground that should have long term implications for outpatient prospective payment and quality improvement efforts.

Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials.

OBJECTIVE: To reconcile conflicting published reports concerning the absolute and comparative clinical efficacy of antimicrobial drugs for acute otitis media in children. STUDY SELECTION: Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Randomized, controlled trials of therapeutic antimicrobial drugs used in the initial empiric therapy for simple acute otitis media were selected by independent, blinded observers, and scored on 11 measures of study validity. Thirty English and three foreign-language articles met all inclusion criteria. DATA EXTRACTION: Data were abstracted for an end point of complete clinical resolution (primary control), exclusive of middle ear effusion, within 7 to 14 days after therapy started. DATA SYNTHESIS: The spontaneous rate of primary control--without antibiotics or tympanocentesis--was 81% (95% confidence interval, 69% to 94%). Compared with placebo or no drug, antimicrobial therapy increased primary control by 13.7% (95% confidence interval, 8.2% to 19.2%). No significant differences were found in the comparative efficacy of various antimicrobial agents. Extending antimicrobial coverage to include beta-lactamase-producing organisms did not significantly increase the rates of primary control or resolution of middle ear effusion. Pretreatment tympanocentesis was positively associated with individual group primary control rates, negatively associated with the ability to detect differences in clinical efficacy and unassociated with resolution of MEE. CONCLUSIONS: Antimicrobial drugs have a modest but significant impact on the primary control of acute otitis media. Treatment with beta-lactamase-stable agents does not increase resolution of acute symptoms or middle ear effusion; initial therapy should be guided by considerations of safety, tolerability, and affordability, and not by the theoretical advantage of an extended antibacterial spectrum.

A method for adjusting capitation payments to managed care plans using multivariate patterns of health and functioning: the experience of Social/Health Maintenance Organizations.

A multivariate procedure for identifying case-mix dimensions from discrete health variables is presented. Since the dimensions are generated only from health use data and not service use data, they can be used for adjust capitation rates to provide incentives to treat persons not currently well integrated in standard health care system (e.g., very ill persons, the uninsured) or to promote specific health outcomes. The procedure is illustrated with data from Social/Health Maintenance Organizations (S/HMO) since they provide both acute and long-term care (LTC) services. Thus, case-mix measures to adjust S/HMO reimbursements have to represent both medical conditions and the degree, and type, of functional impairment. From 31 health and functioning items, six case-mix dimensions, and scores for individuals on each, were calculated. The multivariate distribution of scores in S/HMO enrollees, and in Medicare eligible, comparison samples, were examined in each site to see how their health differed. S/HMO enrollees were healthier and less frail than persons remaining in the Medicare FFS system. Such differences are important in adjusting capitation rates to provide incentive to accept clients with complex health problems.

Computer assisted clinical data analysis.

The Diagnosis Related Groups patient classification scheme coupled with desk top PC technology permits sophisticated analysis of patient medical data. Individuals with no programming knowledge can produce sophisticated analysis. The functionality and structure of the 3M Analytical Workstation are described and example analysis reports are presented.

Social/health maintenance organization and fee-for-service health outcomes over time.

Evaluating the performance of long-term care (LTC) demonstrations requires longitudinal assessment of multiple outcomes where selective mortality and disenrollment, if not accounted for, can give the appearance of reduced (or enhanced) efficacy. We assessed outcomes in social/health maintenance organizations (S/HMOs) and Medicare fee-for-service (FFS) care using a multivariate model to estimate active life expectancy (ALE). S/HMO enrollees and samples of FFS clients in four sites were analyzed and outcome differences assessed for a 3-year period. Results provide insights into S/HMO performance under different conditions and, more generally, into evaluating LTC demonstrations without randomized client and control groups.

A multivariate analysis of disability and health, and its change over time in the National Channeling Demonstration data.

The Channeling Demonstration examined the effects of case management interventions on a variety of outcomes. In the study, longitudinal data were collected from interviews of cases and controls. A multivariate procedure applied to this data identified groups with specific health profiles. Six profiles described health variation over individuals, and time, according to likelihood ratio statistics. Six sets of life tables were calculated, one for each health profile, to estimate the average duration of service use and the "follow-up" services used. A number of differences, and changes, in service use between the six groups were significant.

Use of Medicare services before and after introduction of the prospective payment system.

OBJECTIVE: The case mix-adjusted pattern of use of health care services, especially posthospital care, is compared before and after the introduction of Medicare's Prospective Payment System (PPS). DATA SOURCES: The 1982 and 1984 National Long Term Care Surveys (NLTCS) linked to Medicare administrative records 1982-1986 provide health and health service use data for 12-month periods before and after the introduction of PPS. STUDY DESIGN: Case-mix differences between pre- and post-periods are controlled by using the Grade of Membership model to identify health groups from the NLTCS data. Differences in timing (e.g., hospital length of stay) were controlled using life table models estimated for each health group, that is, service use patterns pre- and post-PPS are compared within groups. PRINCIPAL FINDINGS: Hospital LOS and admission rates declined post-PPS. Changes in the timing and location of death occurred but, overall, mortality did not increase. Changes in post-acute care service use by elderly, chronically disabled Medicare beneficiaries were observed: home health service use increased overall and among the unmarried disabled population. CONCLUSIONS: PPS did not adversely affect quality of care as reflected in mortality or in hospital readmissions. Moreover, the differential use of post-acute care, and changes in hospital LOS by health group, indicate that the system responded, specific to marital status and age, to the severity of needs of chronically disabled persons.

Changes in health service use and mortality among U.S. elderly in 1980-1986.

Concern has emerged about the impact on quality of care of recent changes in Medicare reimbursement for acute hospital episodes (i.e., the introduction of the Prospective Payment System based on the Diagnosis Related Groups Reimbursement methodology). One aspect of those concerns is that very sick patients would be prematurely discharged to nursing homes in which the high level of medical care required would not be available. This was recently studied in terms of changes between 1981 and 1985 in the location of deaths (e.g., hospital, institutional) reported on U.S. death certificates. We analyzed the death certificate data for a longer period of time (1980 to 1986) and stratified the analysis by both age and cause of death--which we felt were important determinants of location of death. We also examined data from the 1982 and 1984 National Long Term Care Surveys linked to data on Medicare service use. In those analyses we could explicitly identify chronically disabled and institutionalized populations and study death rates in different locations within those populations. Our analyses showed little evidence of increased mortality rates due to premature hospital discharge. There were, however, significant changes in the patterns of service use. More home health agency (HHA) and skilled nursing facility (SNF) services were consumed though the rates of death per episode in those venues declined.

Repeated oral administration of activated charcoal for treating aspirin overdose in young children.

The data from our two patients indicates that gastrointestinal dialysis with repeated oral doses of activated charcoal may significantly enhance the elimination of overdoses of salicylate in young children. Limited experience precludes precise recommendations, but current evidence suggests that gastrointestinal dialysis should be evaluated further for treating pediatric salicylate intoxication.

Functionally and medically defined subgroups of nursing home populations.

The functional and health characteristics of nursing home residents in New York State using a multivariate classification procedure are examined in this article. This analysis suggested that these characteristics could be explained in terms of six dimensions. The association of these six dimensions with two existing sets of nursing home case-mix groups was analyzed in order to determine how groups based only on the health and functional characteristics of residents related to groups based primarily on measures of current service use. A number of resident characteristics were not described well by case-mix measures based only on service use, suggesting the need to modify such groups using additional sources of input.