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Traditional analyses of facilities use DRG
(Diagnosis Related Groups) and MDCs (Major Diagnostic Categories)
for comparing cost and utilization metrics across facilities. These analyses are criticized as indiscriminate, because the
underlying algorithms do not incorporate significant differences in
case mix and severity. For
example, a comparison of the average length of stay (ALOS) for
various institutions should recognize the effects of procedure
volume differences as well as the complexity of individual patients
and patients in the aggregate.
3M Health Information Systems developed an
algorithm, known as All Patient Refined DRGs (APR-DRGs), which can
divide hospital admissions into four levels of severity of illness (SOI)
and four risk of mortality (ROM) grades. This approach yields significantly more valid comparisons of
performance among hospitals, such as cost, length of stay,
complication rates and readmission rates. It can also be used to determine which departments are
contributing to overall facility performance and, within each
department, which procedures and physicians are adversely affecting
departmental metrics.
The chart below illustrates the problem of trying to study four
different cases of Acute Cerebrovascular Disease using DRGs vs. APR-DRGs.
The case weights attributed to them are quite different under
CMS DRGs vs. APRs (see the last two lines), and therefore analyses
of cost and utilization metrics will be quite different.
CareAdvantage utilizes APR-DRGs in its analyses
of facility and specialty performance and creates reports, tables
and graphs, incorporating the following case mix and severity
adjusted metrics:
(1)
ALOS by hospital, department, high volume major procedures,
high volume specialists
(2)
Total Cost per stay by hospital, hospital department, high
volume major procedures, high volume specialists
(3)
Actual to expected mortality rate by hospital, hospital
department, high volume major procedures, high volume specialists
(4)
Complication rates for high volume procedures
(5)
Readmission rates by hospital, hospital department, high
volume major procedures, high volume specialists
(6)
Ratio of total costs relative to severity of illness and/or
risk of mortality
(7)
Number and types of AHRQ-Ambulatory Sensitive admissions by
physician
In addition, CareAdvantage can analyze
potential preventable admission rates and 1 day stays by hospital
and principal managing physician.
The resulting set of reports is used for cost,
utilization and quality profiling to generate a balanced report of
facility performance as well as PHO (Physician Hospital
Organization) or IPA (Independent Practice Association) performance.
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