Elsevier

Health Policy

Volume 122, Issue 11, November 2018, Pages 1183-1189
Health Policy

The suitability of a DRG casemix system in the Maltese hospital setting

https://doi.org/10.1016/j.healthpol.2018.08.002Get rights and content

Highlights

  • Diagnosis Related Groups can be suitably applied to the Maltese health system.

  • 636 different Diagnosis Related Groups have been identified.

  • Half of identified Diagnosis Related Groups account for 99% of hospital activity.

  • The coefficient of multiple determination reached 0.25 following a trimming process.

  • A low degree of variability exists amongst identified Diagnosis Related Groups.

Abstract

The healthcare system in Malta is financed through global budgets and healthcare is provided free at the point of use. This paper is a first attempt to examine the feasibility of introducing a Diagnosis Related Groups casemix system for Malta, not necessarily for payment and funding purposes, but as a tool to help describe, manage and measure resource use. This is particularly challenging in view of the constraints and characteristics of a small state country. The study evaluates the applicability of the MS-DRG (Version 27.0) Grouper to describe acute hospital activity on the island. The classification of 151,615 admissions between 2009–2011 resulted in 636 DRG categories. Around half of these DRGs accounted for 99% of the total activity at the hospital, while 296 DRG categories had fewer than 15 cases over the period. Patient length of stay is used to explain resource use and the Coefficient of Multiple Determination obtained was of 0.19 (improving to 0.25 when a number of trimming algorithms were applied). A good proportion of the resulting DRGs had a Coefficient of Variation, which indicates a low degree of variability within the obtained DRG groups. This presents good evidence to support the introduction of a DRG system in Malta particularly in view of the recent drive towards more public-private partnerships and legislation on cross-border patient treatment.

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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