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This study seeks to assist in setting priorities for assessing medical practices and technologies when assessment resources are scarce. It develops an objective index of expected gain from technology assessment, using modified DRG-level data on hospitalizations in NY State. The index uses standard economic concepts to combine measures of resource use, the coefficient of variation in use rates across regions, and the rate at which the incremental value of a medical intervention changes as its rate of use changes, providing a dollar-valued welfare loss from variations. For the entire US in 1987, the highest index occurred for coronary artery bypass graft ($0.95 billion per year), but most of the high-index interventions were nonsurgical, including hospitalizations for psychosis ($0.74 billion per year), cardiac catheterization ($0.62 billion per year), chronic obstructive lung disease ($0.55 billion per year), angina pectoris ($0.46 billion per year), adult gastroenteritis ($0.38 billion per year), adult pneumonia ($0.32 billion per year) and medical back problems ($0.28 billion per year). The top 25 interventions create an annual welfare loss of exceeding $7 billion. The present value of convincingly assessing the correct way to use these interventions sums many years of annual gains from eliminating these welfare losses. The gains from eliminating unexplained variation in medical practices appear greatly larger than costs of necessary studies.
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PMID:Priority setting in medical technology and medical practice assessment. 164 Jul 69

This study analyzed the early effects of the Medicare Prospective Payment System (PPS) on the likelihood of hospital's discharging Medicare beneficiaries to skilled nursing facilities (SNFs), intermediate care facilities (ICFs), and home health agencies. It also examined length of stay before transfer. Discharge abstract data on patients in five DRG groups were studied. Data were obtained from 501 hospitals for the third quarters of 1980, 1983, 1984, and 1985. Multinomial logit and ordinary least squares regression techniques were employed. After controlling for hospital and patient characteristics, including severity of illness, it was found that the probability of transfer increased substantially in virtually all DRGs and discharge destinations studied. This was particularly true for patients with stroke, pneumonia, and major joint and hip procedure. The analysis reveals that PPS increased the rate of discharges to subacute facilities. This effect was stronger for transfer to SNFs than to ICFs and home health agencies. Further, the impact of PPS on transfers was greater in 1985 than in 1984. Lengths of stay before transfer tended to decline in almost all DRGs and destinations examined. However, the effects of PPS on lengths of stay of transferred patients were not statistically significant at conventional levels. The results suggest that payment experiments with broader forms of bundled services are in order, as are experiments with hospital acute-subacute swing beds.
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PMID:Medicare prospective payment and posthospital transfers to subacute care. 313 81

The process of merging and benchmarking clinical and financial data is pivotal to the development of appropriate clinical pathways. Bristol Regional Medical Center (BRMC), facing the challenge of managed care organizations (MCOs), instituted this process and achieved significant cost savings, largely because of the working partnership between the administration and its medical staff. In DRG 89, Simple Pneumonia and Pleurisy, Age Greater than 17 with CC, data adjusted for severity of illness and cost of living were furnished to BRMC by HCIA Inc. Major benchmark or "best practice" variations were incorporated into new clinical pathways, leading to decreased resource use, no compromise in the quality of care, and a beneficial halo effect on other unrelated DRGs.
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PMID:Reducing health care delivery costs using clinical paths: a case study on improving hospital profitability. 760 Feb 38

Detection of nonrandom variation in outcomes with statistical control charts is at the heart of quality improvement techniques. The authors examined the charts' ability to detect variations in outcome of pneumonia. They surveyed Medicare claims data for DRG 89, pneumonia with complications or co-morbidities, from November 1988 through October 1991 at 20 Illinois hospitals with the most Medicare discharges for DRG 89. Control charts were constructed on five outcomes--mean length of stay, range of length of stay, mortality, readmissions, and complications. Standard techniques from industrial statistics were used to construct the historical means and control limits derived from 2 years of data, to plot the monthly samples from the 3rd year of data and to score the control charts for nonrandom variation at less than 1% probability. The observed number of control charts with nonrandom variation was 33 of 100; the expected number was 9.18 (p < 0.0001). Nineteen hospitals had 1 to 3 control charts with nonrandom variation on the five outcomes, whereas only one hospital had none. The number of control charts with nonrandom variation per hospital did not correlate with hospital size, occupancy, teaching status, location, or payer-mix. Statistical control charts provide simple tools for identification of nonrandom variation in outcomes. To the extent that these variations can be related to quality issues, the charts will be useful for quality management.
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PMID:Use of statistical control charts to assess outcomes of medical care: pneumonia in Medicare patients. 817 25

We wished to determine if a claims-based method for severity adjustment would predict mortality or survival in pneumonia based on age, gender, and secondary diagnoses. We used a discriminant analysis model of severity of illness developed from Medicare Part A claims data. Our data base was taken from a hospitalized population age 65 years or older coded as DRG 89 (pneumonia with complications/comorbidities). There were 35,677 cases with a mortality = 11.2% in the derivation cohort from 1989 to 1990, and 19,915 cases with a mortality = 9.8% in the validation cohort from 1991. In the derivation cohort, 98% of patients predicted to live, lived, whereas 18% of patients predicted to die, died. Of the three variables, secondary diagnoses had greatest explanatory power. Receiver operating characteristic curves showed that the model performed best at 40% survival. Results were confirmed with the 1991 validation cohort. The model could be applied to hospitals with as few as 172 discharges. This simple, claims-based method can predict survival in pneumonia. It may be useful in selecting medical records for intensified review of medical quality.
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PMID:Secondary diagnoses as predictive factors for survival or mortality in Medicare patients with acute pneumonia. 897 35

Inpatient mortality has increasingly been used as an hospital outcome measure. Comparing mortality rates across hospitals requires adjustment for patient risks before making inferences about quality of care based on patient outcomes. Therefore it is essential to dispose of well performing severity measures. The aim of this study is to evaluate the ability of the All Patient Refined DRG system to predict inpatient mortality for congestive heart failure, myocardial infarction, pneumonia and ischemic stroke. Administrative records were used in this analysis. We used two statistics methods to assess the ability of the APR-DRG to predict mortality: the area under the receiver operating characteristics curve (referred to as the c-statistic) and the Hosmer-Lemeshow test. The database for the study included 19,212 discharges for stroke, pneumonia, myocardial infarction and congestive heart failure from fifteen hospital participating in the Italian APR-DRG Project. A multivariate analysis was performed to predict mortality for each condition in study using age, sex and APR-DRG risk mortality subclass as independent variables. Inpatient mortality rate ranges from 9.7% (pneumonia) to 16.7% (stroke). Model discrimination, calculated using the c-statistic, was 0.91 for myocardial infarction, 0.68 for stroke, 0.78 for pneumonia and 0.71 for congestive heart failure. The model calibration assessed using the Hosmer-Leme-show test was quite good. The performance of the APR-DRG scheme when used on Italian hospital activity records is similar to that reported in literature and it seems to improve by adding age and sex to the model. The APR-DRG system does not completely capture the effects of these variables. In some cases, the better performance might be due to the inclusion of specific complications in the risk-of-mortality subclass assignment.
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PMID:[Evaluation of the capacity of the APR-DRG classification system to predict hospital mortality]. 1240 5

Serological diagnosis of Chamydophila pneumoniae is usually undertaken by complement fixation test (CFT) or by microimmunofluorescence (MIF). A number of commercial methods for detecting C. pneumoniae-specific IgG have been developed. The aim of this study was to compare the performance characteristics of six methods for the diagnosis of pneumonia due to C. pneumoniae, including CFT (in house), MIF (Vircell, Spain), and four ELISAs (Medac, Germany; Savyon, Israel; Serion, Germany; and DRG, Germany). ELISA-Medac, ELISA-Savyon, ELISA-DRG and MIF use C. pneumoniae antigens while ELISA-Serion and CFT use Chlamydophila genus-specific antigen. Acute and convalescent samples from 85 pneumonia patients were studied. Using CFT, cases were initially classified as due to Chlamydophila (43 cases); to other agents (23 cases) (influenza A and B, Mycoplasma pneumoniae, respiratory syncytial virus, adenovirus and Legionella pneumophila); or as negative (19 cases). Cases were considered positive if they showed seroconversion, a significant rise in titer or high titer; and were finally classified as positive if they gave a positive result in at least three assays. Sensitivity values ranged from 87% to 97.8%; and specificity from 84.6% to 97.4%. In conclusion, the assays compared appear to be useful tools for the diagnosis of pneumonia due to Chlamydophila.
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PMID:Detection of Chlamydophila pneumoniae IgG in paired serum samples: comparison of serological techniques in pneumonia cases. 1668 27

Since 2000 there has been sufficient evidence that chest X-rays are unnecessary in infants and children with uncomplicated lower respiratory tract infection. The reason is that neither the diagnosis nor the first therapeutic decisions will be influenced by the result of this procedure, and especially so if children have been infected with the respiratory syncytial virus. However, epidemiological studies in Germany reveal an ongoing use of chest X-ray in these cases. This might suggest that the X-ray images are taken as "proof" of pneumonia, which indeed pays off in the German DRG (Diagnosis Related Groups) system since hospitals receive a higher reimbursement for RSV pneumonia than for RSV bronchiolitis.
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PMID:[Transferability of trial results into clinical practice: examples taken from paediatric practice]. 1983 10

Fast-track surgery is a comprehensive perioperative treatment concept that has been successfully performed and widely accepted in adult surgery since the 1990s. The crucial aim is to speed up convalescence and to avoid perioperative complications as pneumonia and thrombosis. Compared to conventional treatment strategies, hospital stays are substantially reduced. In the paediatric field fast-track surgery is not generally established. However, in recent studies a high efficiency of paediatric surgical fast-track procedures with respect to medical, psychological, economical and ethical parameters has been shown. It has been confirmed that early convalescence leads to an increase of satisfaction of the patients and their parents without higher complication rates. Shorter hospital stays lead to reduced expenses for the health insurances and parents. Fast-track concepts are not implemented in the German reimbursement system G-DRG. Thus, problems with intensified nursing and reimbursement remain to be solved.
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PMID:[Fast-track paediatric surgery]. 2002 Mar 82

The study objective was to examine hospital mortality outcomes and structure using 2008 patient-level discharges from general community hospitals. Discharges from Florida administrative files were merged to the state mortality registry. A cross-sectional analysis of inpatient mortality was conducted using Inpatient Quality Indicators (IQIs) for acute myocardial infarction (AMI), congestive heart failure (CHF), stroke, pneumonia, and all-payer 30-day postdischarge mortality. Structural characteristics included bed size, volume, ownership, teaching status, and system affiliation. Outcomes were risk adjusted using 3M APR-DRG. Volume was inversely correlated with AMI, CHF, stroke, and 30-day mortality. Similarities and differences in the direction and magnitude of the relationship of structural characteristics to 30-day postdischarge and IQI mortality measures were observed. Hospital volume was inversely correlated with inpatient mortality outcomes. Other hospital characteristics were associated with some mortality outcomes. Further study is needed to understand the relationship between 30-day postdischarge mortality and hospital quality.
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PMID:Examination of hospital characteristics and patient quality outcomes using four inpatient quality indicators and 30-day all-cause mortality. 2272 70


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