The process and result of implementing a new grouping ... · The process and result of implementing a new grouping logic for acute outpatient care Katarina Bjerg-Holm The Danish Health

The process and result of implementing a new grouping logic

for acute outpatient care

Katarina Bjerg-Holm

The Danish Health Data Authority

Emergency Room (ER) closed - New Acute Ambulatory Ward

• ER closed -> New AAW

• New guidelines for registration

Need for a change in the Danish DRG-system

Change in the Danish DRG-system

• Challenge – New registration = no data!

• Simple temporary transition model in the grouping logic 2014

• More advanced model in the grouping logic from 2015 and forward

• Possible to test model in 2014

Agenda

• A little background history

• What is an acute admission?

• How did we go about creating a specific AAW grouping logic?

• The result of implementing the new model

• What did we learn from the process?

A little background history…

• From NordDRG to DkDRG

• Between 1999 and 2001 Denmark used the NordDRG grouping logic

• In 2002 we constructed the Danish DRG grouping logic - DkDRG, based on the NordDRG logic with distinct local adaptation

• Danish DkDRG - 2 separate groupers:

• Inpatient Hospital admission

• Outpatient Ambulatory care casemix

• Now including telemedicine & other substitutions for ambulatory care

A little background history… The in’s and out’s of the Danish grouping logic

Gray area patient grouping

Admitted inpatients

DkDRG-system

Outpatient Ambulatory care

DAGS-system

A little background history… The in’s and out’s of the Danish grouping logic


DkDRG-system (Gray area groups)

DAGS-system

DkDRG

DAGS

ER Group

Diagnosis-groups

Visits

Procedure-groups

Gray area Groups

Groups for same-day treatment

Substitution-groups

The Big Change

Oh no what now?!

What happened?

• The Danish Health Authority recommended a new organization of ER and Acute Ambulatory Units

• It was up to the 5 regions to interpret and implement the new recommendations

• Out with ER and in with Acute Ambulatory Ward

Why the AAW?

• The overall objective:

• To ensure high quality and efficiency in evaluation and treatment of critically ill or injured patients.

• The acute patient must always meet a health care service where the right specialist skills and facilities are present regardless of time and place

• Reduction from around 40 Hospitals with an ER open 24 hours a day

New organization with 21 acute Hospitals with new acute ambulatory wards open 24 hours a day

What happened?

• New registration guidelines were implemented to reflect the new recommendation and the new organizational structures

New registration from January 1’st 2014:

• No registration of ER patient status

• New registration of Acute Ambulatory Admission

• New admission timestamp and discharge timestamp

What is an acute admission in Danish terminology?

• Patients are sent to the AAW from accident and emergency (A&E) or can be referred directly by their GP.

What is an acute admission in Danish terminology?

• Patients are sent to the AAW from accident and emergency (A&E) or can be referred directly by their GP.

• Patients receives treatment in the ambulatory care area and is discharged after treatment/observation

• Patients can move directly to a specialist inpatient ward on the day of the admission

• Ambulatory care

• One to three overnight stays - patient can remain in the AAW short stay unit

What??

Why are acute admissions special

• These patients break the “rules” and boundaries of inpatient/outpatient definitions

• The patient flow through the hospital is very much dependent on local organization

How are the Acute Ambulatory Wards organized

• Some are ambulatories with outpatients

• Some are admission wards with outpatients

• Some are ambulatories with overnight patients

• Some are a mix of all three

• At least 13 different path through the acute area

The acute patient

Acute Outpatient

Acute O

Acute Inpatient

Acute I Same payment for the same acute patient

Our goal

Are acute admissions really that special?

• They aren’t all that special any more

• Often the exact same treatment as planned intervention – same drain on resources

• Often in the same location as planned intervention and treatment

• Often the same staff

• Don’t just take place at the Acute Ambulatory Ward

• The acute patient is more than just the “old” ER-patient

Acute contacts in the DAGS System



DAGS-system

DkDRG

DAGS

ER Group

Diagnosis-groups

Visits

Procedure-groups

Gray area Groups


Substitution-groups

Acute contacts in the DAGS System



DAGS-system

DkDRG

DAGS

Diagnosis-groups

Visits

Procedure-groups

Gray area Groups


Substitution-groups

AA Groups

Data challenges

• New registrations agreed upon in 2012

• To be implemented on January 1st 2014

• No data at the point of designing the new grouping logic

• The logic for 2014 was made in the fall of 2012

• The logic for 2015 was made in the fall of 2013

• There was no way to logically deduce the new registrations from the old registrations

• Test data was based on a qualified “guestimate”

First Model

• The Danish Health Data Authority

• Created a model “on paper” in 2012 to reflect the registration guidelines

• Suggested to implement it in the 2014 grouping logic

• Our goal with the First Model was

• To be able to handle differences in organization

• Should not be too complex

First Model - on paper and not implemented

Acute Time > 12

Hours DkDRG

Trauma

Small surgical injuries

Small injuries

Non visits, fee = 0 kr.

Observation for accidents and poisoning

Traumareception

Special Acute grouping Logic

DAGS

Medical illness

DkDRG - Gray Area Groups

How did we organize the work?

• The First Model was discussed with the Danish DRG-board

• The DRG-board has the final say

• The members of the Board are representatives from the Regions, Danish Regions, Local Government Denmark (The interest group and member authority of Danish municipalities) and The Ministry of Health

• It was decided to establish an Expert Group that included representatives from the Regions

• The Group should, together with The Danish Health Data Authority, come up with a recommendation to the DRG-Board

How did we organize the work?

• The First Model was discussed with the Expert Group

• Conclusion in 2012

• A simple temporary transition model was agreed upon for 2014

• 1 ER-similar-group – Based on the primary diagnosis

• Decision to further work with the First Model in 2013

• Goal: to implement a more advanced model in the grouping logic for 2015

Model in 2015 - the implemented model

Acute Inpatient

DkDRG

DAGS - Now including a new special Acute

Grouping Logic

Acute Outpatient

DkDRG - Gray Area

Groups

Model in 2015 Outpatient Ambulatory care

DkDRG-system (Gray area-groups)

DAGS-system

DkDRG

DAGS

Diagnosis-groups

Visits

Procedure-groups

Gray area Groups


Substitution-groups

AA Groups

Model in 2015


DkDRG-system (Gray area-groups)

DAGS-system

DkDRG

DAGS

Diagnosis-groups

Visits

Procedure-groups

Gray area Groups


Substitution-groups

AA Groups

AA Groups

Model in 2015

5 AA-groups in DAGS 2015

AA01A Trauma

The DRG for Traumareception is a gray area group

AA01B Small surgical injuries

AA01C Small injuries

AA01D ”Non visits”, fee = 0 kr.

AA01E Observation for accidents and poisoning

Gray area group - Traumareception

Evaluation of the model

• In 2014 it was possible to test the logic with correct data

• Registration started January 1’st 2014

• Test was done during the fall of 2014

• Changes could be implemented in the grouping logic for 2016

• Evaluation together with the Expert Group

• Result:

• One group was deleted – no activity

Model in 2016


AA01A Trauma

The DRG for Traumareception still a gray area group


AA01D “Non visits”, fee = 0 kr.



AA01B Small surgical injuries

Model in 2017 - Another change

• The emergency doctor service is handled in the primary sector by the GPs • Activity not a part of the Danish DRG System

• In 2014 one Region decided to make a new emergency line (Medical Helpline 1813) • Replacing the emergency doctor service

• Organized and implemented as part of the hospital activity and therefore the activity is part of the DRG System

• Staffed by physicians and nurses

Model in 2017 - Another change

• New Medical Helpline activity is not handled in the logic for 2016

• Unable to distinguish the activity from other outpatient activity

• Together with the National DRG Board it was decided to develop a new acute DRG-group that could include this new outpatient activity – and other similar activity with a relatively light pull on resources

Model in 2017


AA01A Trauma

The DRG for Traumareception still a gray area group


AA01D “Non visits”, fee = 0 kr.



AA01B Less servere acute care

The Result

• More AA contacts than the “old” ER contacts

895.779

1.166.907

0

200.000

400.000

600.000

800.000

1.000.000

1.200.000

1.400.000

ER contacts - 2013 AA contact - 2015

ER contacts vs AA contacts Only outpatients

The Result of the new AA-groups

• ER patients group as expected

40,2%

32,7%

1,1% 4,1%

21,8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Acute Procedure Sameday Diagnosis Visit

ER patients (activity 2013) - 2016 logic Ordered by type of casemixgroup

The Result of the new AA-groups

• AA activity group as expected

29,2% 29,4%

1,3%

35,3%

4,7% 0,1% 0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

40,0%

Acute Procedure Sameday Visit Diagnosis Substitution

AA contacts (Outpatients 2015) Ordered by casemixgroup

Activity in AA-groups – DAGS 2016

• In 2015 there is 340.512 contacts in the AA-groups (2016 logic)

• 39 acute outpatient contacts (2015 activity) is grouped to the gray area group Traumareception

AA01A Trauma 5.869

AA01C Small injuries 322.696

AA01D Non visits 11.097

AA01E Observation for accidents and poisoning 850


• Mean of length of stay is above 1 for all groups – outpatients only

Mean of length of stay

Casemix Acute outpatients with length of stay less than 6 days (340.204 contacts)

AA01A Trauma 1,4

AA01C Small injuries 2,0

AA01D Non visits 1,5

AA01E Observation for accidents and poisoning 1,4

Total 1,7


• Not much difference between the regions - overall

1,1%

97,7%

0,7% 0,6% 1,2%

97,1%

1,4% 0,3% 2,6%

96,0%

1,1% 0,3% 1,6%

91,8%

6,4%

0,2% 1,6%

96,5%

1,8% 0,1% 0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

90,0%

100,0%

AA01A AA01C AA01D AA01E

Activity in groups between regions

1081

1082

1083

1084

1085

What did we learn from the process?

• Very important with help from the Regions and Hospitals • Gives better accept of the new grouping system • New ideas:

• Went from having many new groups to reusing the ones we have • New group for the less severe acute outpatient

• It is possible to make a new logic without data… • BUT it is difficult and we would prefer to have testdata before making these big

changes • Huge uncertainty for the users of the system

• Big difference in the way the hospitals are organized

Model in 2018

• Is being developed together with an Expert Group • And off course also in close contact with the clinical societies

• Big changes in the Danish DRG-System • All activity is grouped with the same system

• Accelerated activity is grouped together

• Organizational differences are attempted eliminated in the grouping

• Acute Ambulant groups will be a part of the new system

The process and result of implementing a new grouping logic for acute outpatient care

Katarina Bjerg-Holm The Danish Health Data Authority

Email: [email protected]

Questions?

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The process and result of implementing a new grouping ... · The process and result of implementing a new grouping logic for acute outpatient care Katarina Bjerg-Holm The Danish Health