The suitability of a DRG casemix system in the Maltese hospital setting
Introduction
The ability to measure the outcome of health care is critical to improving the effectiveness, efficiency and accountability of any health care system. Hospitals are deeply rooted in the political and administrative organisation of their country and typically account for the majority of spending by Government within the health care sector. Diagnosis Related Groups (DRGs) may help policy makers obtain an estimate of the activity undertaken within the hospital. This can help to better understand and measure the output of the hospital entity.
The multi-product nature of hospital output is a major factor to be dealt with when defining hospital activity. Classes of patients with similar clinical attributes and similar processes of care provide the necessary framework to aggregate patients into case types or products which entail the use of similar resources. DRGs are a management tool which views the delivery of health care as a service, indeed as a production process in which outputs (health care episodes) are delivered to consumers (patients).
The primary focus of this paper is the measurement of output in the Maltese health care sector through the use of a DRG casemix system. This will assist policy makers to assess and adopt the appropriate policy guidelines to ensure the sustainability of the continued provision of free health care services. By applying DRGs in this context, the findings of the study will also contribute to the debate of the relevance of such systems when applied to small countries which may have quite particular hospital characteristics. While recognising the limited availability of published work on the connection between country size, health systems and their outcomes, the broader question of constraints and opportunities of small countries has been extensively analysed by a number of authors [1,2].
To date, there has not been a study on the application of a DRG casemix classification system to health care activity in Malta. The majority of countries which introduced DRG systems as part of their reform initiatives have imported a pre-existing casemix system from another country - even though it may not have fully reflected their own health care practice patterns [3]. It is, typically, only later that countries decide to refine the implemented casemix system to better reflect their own health care system.
The results presented in this paper show that there is a good basis for recommending the introduction of a DRG based system to describe the hospital output activities in the Maltese health care system. On this basis, it may serve as a tool for the better measurement and management of resources across the health sector in this context.
Section snippets
Background
The motives underlying the introduction of DRG systems, as well as the particular design features of the systems, vary greatly across countries [4]. Such motives continue to evolve following the introduction of the DRG system, and may shape their development [5,6]. Once DRGs are introduced, their primary use within most health care systems is for benchmarking purposes and to commission health care services. In later years, the aims evolve, with DRGs being used as an internal resource management
Data and methods
This study uses patient level data provided by the Clinical Performance Unit of Mater Dei hospital for the years 2009–2011. Three different datasets, namely i. the Surgical and Operations Register; ii. the Admissions and Transfers Discharge Database; and iii. the Hospital Activity Analysis Database, were employed. These were integrated at patient level using an encrypted patient ID code. A mapping algorithm was used to map hospital activity data to the requirements of the MS-DRG (Version 27.0)
Results
The classification of the 151,615 cases using MS-DRG resulted in 636 different DRGs, of which approximately 55% accounted for 99% of the total activity generated in the hospital. Further analyses showed that around 2% of the DRGs represented approximately 31% of the activity at the hospital. There were 296 DRGs with fewer than 15 cases each over the three-year period (1481 patient cases in total). The ALOS for all hospital activity stood at 4 days. Out of these, only 31 DRGs (with fewer than 15
Discussion
The values of R2 obtained in this study were around 0.3 for LOS using trimmed data. The R2 values obtained from untrimmed data were low (0.19) but this has to be viewed in line with the known quality limitations of the available hospital data. R2 values also varied across the different MDC categories, with some categories reaching levels close to 0.6 once trimming had been performed. R2 values based on untrimmed data may indeed be more than 20 percentage points lower after outliers are removed [
Conclusion
This study makes a first attempt at examining the relevance of using the MS-DRG grouper to describe hospital activity in Malta. The results show that the CV and the R2 coefficients obtained provide a suitable basis for recommending the use of DRGs in the Maltese health care system. This study concludes that the MS-DRG Grouper software can be applied to the currently available data for the Maltese health care sector with relatively good results. Policy makers require accurate information on
Declarations of interest
None.
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