Prospective payment to encourage system wide quality improvement

Background: Casemix-based inpatient prospective payment systems allocate payments for acute care based on what is done within an episode of care without regard for the outcome. To date, they have provided little incentive to improve quality. The Centers for Medicare & Medicaid Services have recently excluded 8 avoidable complications from their payment system. Objective: This study models an inpatient prospective payment system that comprehensively excludes not-present-on-admission and other complication diagnoses from the entire funding process, effectively adding a diagnosis-related group (DRG)-specific average complication payment across all discharges. Research Design: Complication-averaged cost weights were estimated using the same patient level cost dataset used for estimating the relative resource weights for Victorian public hospitals in 2006-07. All codes with a "C" prefix (secondary diagnoses that are coded as having arisen after admission) and codes that define a condition that prima facie represent a specific complication of care were excluded from the code string. The episodes were then regrouped to DRGs and new complication-averaged cost weights were developed. Results: When complication codes were excluded across 1.2 million discharges, 1.37% became ungroupable, 14.86% included at least one complication diagnosis code, and 1.56% grouped to another DRG. Modeled funding for individual metropolitan hospitals in Victoria, Australia, was redistributed by -2.5% to 1.8%. Conclusions: The cost weights reflect the average cost of preventable and unpreventable complications and have the potential to drive improvements in clinical care. This study is in contrast to previous studies estimating the funding impact of preventing all complications

Prospective payment to encourage system wide quality improvement

Background: Casemix-based inpatient prospective payment systems allocate payments for acute care based on what is done within an episode of care without regard for the outcome. To date, they have provided little incentive to improve quality. The Centers for Medicare & Medicaid Services have recently excluded 8 avoidable complications from their payment system. Objective: This study models an inpatient prospective payment system that comprehensively excludes not-present-on-admission and other complication diagnoses from the entire funding process, effectively adding a diagnosis-related group (DRG)-specific average complication payment across all discharges. Research Design: Complication-averaged cost weights were estimated using the same patient level cost dataset used for estimating the relative resource weights for Victorian public hospitals in 2006-07. All codes with a "C" prefix (secondary diagnoses that are coded as having arisen after admission) and codes that define a condition that prima facie represent a specific complication of care were excluded from the code string. The episodes were then regrouped to DRGs and new complication-averaged cost weights were developed. Results: When complication codes were excluded across 1.2 million discharges, 1.37% became ungroupable, 14.86% included at least one complication diagnosis code, and 1.56% grouped to another DRG. Modeled funding for individual metropolitan hospitals in Victoria, Australia, was redistributed by -2.5% to 1.8%. Conclusions: The cost weights reflect the average cost of preventable and unpreventable complications and have the potential to drive improvements in clinical care. This study is in contrast to previous studies estimating the funding impact of preventing all complications

Evaluation of a model for total body protein mass based on dual-energy X-ray absorptiometry: comparison with a reference four-component model

The aim of the present study was to evaluate a model of body composition for assessing total body protein (TBP) mass using dual-energy X-ray absorptiometry (DXA), with either measured or assumed total body water (TBW); it was intended to provide a less complex or demanding alternative technique to, for example, the four-component model (4-CM). The following measurements were obtained in healthy adults (n 46) aged 18–62 years, and children (n 30) aged 8–12 years: body weight (BWt), body volume (BV; under-water weighing), TBW (2H-dilution space or predicted using an assumed hydration fraction of fat-free mass (HFffm)), bone mineral content (BMC; DXA) and fat-free soft tissue (FFST; DXA). TBP was calculated using the 4-CM (TBP=3·050BWt-0·290TBW-2·734BMC-2·747BV) and the DXA model (TBP=FFST-0·2305BMC-TBW). DXA measurements were obtained using the Lunar DPX (Lunar Radiation Corporation, Madison, WI, USA) or Hologic QDR 1000/W (Hologic, Waltham, MA, USA). Precision of the DXA model for TBP with measured TBW (4·6–6·8 % mean TBP) was slightly worse than the 4-CM (4·0–5·4 %), whereas that modelled with assumed HFffm was more precise (2·4–5·2 %) because it obviated imprecision associated with measuring TBW. Agreement between the 4-CM and DXA model with measured TBW was also worse (e.g. bias, 15 % of the mean; 95 % limits of agreement up to ±39 % for adults measured on the Lunar DPX) than when a constant for HFffm was assumed (3·7 % and ±21 % respectively). Most of the variability in agreement between these various models was due to interpretation of biological factors, rather than to measurement imprecision. Therefore, the DXA model, which is less complex and demanding than the 4-CM, is of value for assessing TBP in groups of healthy subjects, but is of less value for individuals in whom there may be substantial differences from reference 4-CM estimates

Risk adjustment policy options for casemix funding: international lessons in financing reform

Risk adjustment, Casemix funding, Diagnosis-related groups, Hospital costs,

Energy metabolism in infants with cystic fibrosis

Objective: To determine whether a defect in energy metabolism exists in infants with cystic fibrosis (CF). Design: Unselected, newly-diagnosed subjects With CF (n = 46) and 24 healthy infants age

Height and weight fail to detect early signs of malnutrition in children with cystic fibrosis

Background: Many children with cystic fibrosis grow poorly and are malnourished. This study was undertaken to determine whether extensive anthropometry could detect early signs of malnutrition in prepubertal children with cystic fibrosis to prevent deficits in height and weight