Apresentação Oral na 29º edição da ISQua, congresso da International Society for Quality in Health Care (Genebra 2012) com o título: Risk Adjustment for DRG-Case Mix for Performance Evaluation of Hospital Estadual de Diadema

1. Fábio Leite Gastal: Chief Medical Operations of Mãe de Deus Hospital & Health System
Mario Hideo Kono: Medical Director of Hospital Estadual de Diadema
Nacime Salomão Mansur: SPDM External Hospitals Controller
Marcelo Neubauer de Paula: Project Director of Value Health Company
Risk Adjustment for DRG-Case Mix for
Performance Evaluation of “Hospital
Estadual de Diadema” (São Paulo)

2. Risk Adjustment for DRG-Case Mix for
Performance Evaluation of Diadema State
Hospital
Estadual de
Hospital
Diadema

3. Performance Evaluation using Stratified Risk
Adjustment by DRG (Diagnosis Related Groups)
Introduction:
60’s / Yale University developed DRG patient classification process
80’s / Medicare, Medicaid and HMO´s (US) DRG as a payment system
80’s / First Brazilian DRG study from State University Hospital from São
Paulo in Riberão Preto
80’s & 90’s / European Countries adopted the DRG System for hospital
performance evaluation and risk management

4. 2004 / DRG Study was carried out in 14 State Public Hospitals in São
Paulo, Brazil (Internal Benchmarking)
2007 / First study for a private company (HMO): 190,000 hospital
admissions, 56 Hospitals (Internal Benchmarking)
2010 / DRG study at SPDM (São Paulo State Society for Medicine
Development) Hospital Network (7 facilities). Risk evaluation and clinical
quality indicators were done by DRG case mix classification with external
benchmarking (65 facilities and 1.47 million hospital admissions).

5. Objectives
Hospital Evaluation using Risk Adjustment stratified by DRG
Case: “Diadema State Hospital”

6. Coding Systems used in Brazil
For diseases:
• ICD – 10
For procedures:
Public Health Services:
• SUS procedures table
Private Health Services:
• CBHPM - Brazilian Classification of Procedures

7. Methods:
External Benchmarking (65 Public Hospitals): 1.47 million
hospital admissions, 2009/2010
Database: Tab Win – Brazilian National Health System
Database
Stratification by AP-DRG 23
Case Mix Classification by Mortality and Length of Stay (LOS)
Defined Real Values and Ideal Values for Mortality and Length
of Stay (LOS) based on Hospital Case Mix Methodology

8. Results on the table charts:
Real Length of Stay vs Estimated Length of Stay (LOS)
DRGs with better impact on Length of Stay control.
Real Mortality vs Estimated Mortality
DRGs with better impact on Mortality control.

9. Length of Stay (LOS)
3
3,5
4
4,5
5
2009 2010
LengthofStay
(days)
Real Expected
The results show that the Length of Stay in HED was significantly shorter than expected.

10. DRGs with Great Impact on reducing
Length of Stay (LOS) - 2009
N: Number of hospital admissions
Real: Real Length of Stay (LOS - days)
Expected: Length of Stay (LOS) that HED had to be if its performance is the same of the Case Mix for each DRG
Difference: Real – Expected
Impact: Difference vs N
AP-DRG Description n Real Expected Difference Impact
268 SKIN,SUBCUT TISSUE,BREAST PLASTIC PROC 891 1,1 3,6 -2,5 -2227,5
618 BWT 2000-2499G W/O SIG OR PR W MAJ PROB 561 8,7 11,9 -3,2 -1795,2
266 SKN GRFT,DEBRID EX SKN ULCR,CELLUL WO CC 641 1,4 3,5 -2,1 -1346,1
771 RSP INFCT,INFL X SIMP PNEUM AGE<18 WO CC 376 5,4 6,4 -1,0 -376
80 RSP INFCT,INFL X SIMP PNEUM AGE>17 WO CC 149 7,2 9,3 -2,1 -312,9
373 VAGINAL DELIVERY W/O COMPLIC DIAGNOSES 1278 2,6 2,8 -0,2 -255,6
867 LOC INC&REM INT FIX DEV EX HIP&FEM WO CC 266 2,1 3,0 -0,9 -239,4
769 SEIZURE & HEADACHE AGE 0-17 W/O CC 204 3,1 4,1 -1,0 -204
77 OTHER RESP SYSTEM O.R. PROCEDURES W/O CC 64 8,2 11,0 -2,8 -179,2
270 OTH SKIN,SUBCUT TISS,BREAST PROC W/O CC 94 1,5 3,3 -1,8 -169,2

11. DRGs with Great Impact on reducing
Length of Stay (LOS) - 2010
N: Number of admissions
Real: Real Length of Stay (LOS - days)
Expected: Length of Stay (LOS) that HED had to be if its performance is the same of the Case Mix for each DRG
Difference: Real – Expected
Impact: Difference vs N
AP-DRG Description n Real Expected Difference Impact
618 BWT 2000-2499G W/O SIG OR PR W MAJ PROB 834 8,5 11,8 -3,3 -2752,2
266 SKN GRFT,DEBRID EX SKN ULCR,CELLUL WO CC 1282 1,1 3,3 -2,2 -2820,4
268 SKIN,SUBCUT TISSUE,BREAST PLASTIC PROC 238 1,1 3,5 -2,4 -571,2
769 SEIZURE & HEADACHE AGE 0-17 W/O CC 270 2,3 3,7 -1,4 -378
77 OTHER RESP SYSTEM O.R. PROCEDURES W/O CC 110 8,1 11,2 -3,1 -341
270 OTH SKIN,SUBCUT TISS,BREAST PROC W/O CC 107 1,7 3,4 -1,7 -181,9
189 OTHER DIGESTIVE SYSTEM DX AGE >17 W/O CC 156 2,9 4,0 -1,1 -171,6
423 OTH INFECTIOUS & PARASITIC DIS DIAGNOSES 142 8,2 9,2 -1,0 -142
158 ANAL & STOMAL PROCEDURES W/O CC 78 1,8 3,5 -1,7 -132,6
867 LOC INC&REM INT FIX DEV EX HIP&FEM WO CC 221 2,3 2,9 -0,6 -132,6

12. Mortality
0
0,5
1
1,5
2
2,5
3
3,5
2009 2010
Real Expected
The results of Mortality in HED was significantly lower than expected.
%

13. DRGs with Great Impact to reduce
Mortality - 2009
N: Number of admissions
Real: Mortality Tax (%)
Expected: Mortality that HED had to be if its performance is the same of the Case Mix for each DRG
Difference: Real – Expected
Impact: Difference vs N
AP-DRG Description n Real Expected Difference Impact
618 BWT 2000-2499G W/O SIG OR PR W MAJ PROB 561 1,1% 5,2% 0,0 -23,001
423 OTH INFECTIOUS & PARASITIC DIS DIAGNOSES 113 8,0% 21,6% -0,1 -15,368
189 OTHER DIGESTIVE SYSTEM DX AGE >17 W/O CC 135 0,0% 5,7% -0,1 -7,695
88 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 196 0,5% 4,4% 0,0 -7,644
761 TRAUMATIC STUPOR & COMA,COMA > 1 HR 82 9,8% 16,6% -0,1 -5,576
422 VIRAL ILL,FEVER OF UNKNWN ORIG AGE 0-17 18 16,7% 46,7% -0,3 -5,4
80 RSP INFCT,INFL X SIMP PNEUM AGE>17 WO CC 149 12,8% 16,1% 0,0 -4,917
268 SKIN,SUBCUT TISSUE,BREAST PLASTIC PROC 891 0,0% 0,5% 0,0 -4,455
127 HEART FAILURE & SHOCK 76 10,5% 16,8% -0,1 -4,788
475 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 14 14,3% 43,8% -0,3 -4,13

14. DRGs with Great Impact to reduce
Mortality - 2010
N: Number of admissions
Real: Mortality Tax (%)
Expected: Mortality that HED had to be if its performance is the same of the Case Mix for each DRG
Difference: Real – Expected
Impact: Difference vs N
AP-DRG Description n Real Expected Difference Impact
618 BWT 2000-2499G W/O SIG OR PR W MAJ PROB 834 0,8% 4,9% 0,0 -34,194
423 OTH INFECTIOUS & PARASITIC DIS DIAGNOSES 142 9,9% 21,9% -0,1 -17,04
189 OTHER DIGESTIVE SYSTEM DX AGE >17 W/O CC 156 0,6% 5,5% 0,0 -7,644
127 HEART FAILURE & SHOCK 75 9,3% 16,6% -0,1 -5,475
77 OTHER RESP SYSTEM O.R. PROCEDURES W/O CC 110 8,2% 13,0% 0,0 -5,28
88 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 193 2,1% 4,5% 0,0 -4,632
810 INTRACRANIAL HEMORRHAGE 27 14,8% 30,9% -0,2 -4,347
422 VIRAL ILL,FEVER OF UNKNWN ORIG AGE 0-17 23 26,1% 44,4% -0,2 -4,209
206 DISOR LIVER EX MALIG,CIRR,ALC HEPA WO CC 71 2,8% 8,0% -0,1 -3,692
268 SKIN,SUBCUT TISSUE,BREAST PLASTIC PROC 638 0,0% 0,5% 0,0 -3,19

15. Conclusions
Stratification by DRG can show hospital performance
comparing actual with expected results.
The Length of Stay (LOS) and mortality in HED were reduced
when compared with the expected results and presenting
improvement of the hospital performance.

16. www.vhis.com.br
marcelo.neubauer@vhis.com.br
fabio.gastal@maededeus.com.br
THANK YOU