six years of hospitalization in portuguese public hospitals

Six years of hospitalizationSix years of hospitalizationin Portuguese public in Portuguese public

hospitalshospitalsAn analysis of the major causes of admission

Faculty of Medicine – University of Porto

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Structure

Discussion

Results Methods

Introduction

Purposes

Researchwork


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The main purpose of this work is to analyse six years of hospitalization in Portuguese public hospitals, describing and emphasizing the major causes of admission.

In this sense, it is essential to compare demographic characteristics of the patients as well to point out hospitalization’s causes and its temporal evolution.

Purposes


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Introduction

Diagnosis Related Groups (DRGs) are a systematic classification of the hospitalized patients in hospitals that attend acute cases (Palmer et al, 1986).

This system was developed in the late 60’s by a multidisciplinary team of Yale University and the main researchers were Robert B. Fetter and John Thompson.


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DRG

Patient characteristics Clinical aspects ICD diagnoses

Gender

Age

Surgical procedures

Discharge status

Comorbidity

Complications

Patient’s main diagnosis

Patient’s secondary diagnosis

The categories should be consistent in terms of the anatomy, physiopathologic classification and clinical treatment of the patients. On the other hand each group should contain patients with similar patterns in what concerns to the resources consumption.


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The main purposes of DRG are:

to evaluate and improve the management, planning and revision of the hospital utilization;

to define the complexity of the hospital profile (case-mix), in terms of consumption of resources during hospitalization;

to finance the previous payment of treatments;

to measure and examine the hospital products (Fetter, 1989).


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In Portugal, the DRG system was implemented in 1990.

According to some studies, the DGR payment system seems to have had a positive impact on productivity and technical efficiency of the hospital services in Portugal (Dismuke et al,

1999).


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Methods

The sample of this study:

- All the hospitalizations that have occurred between 1999 and 2004 in Portuguese public hospitals in a universe of 89 hospitals, located in the continent.

- The data base was provided by the IGIF and incorporates data relating to 34 central hospitals, 36 general district hospitals and 19 district hospitals level 1, amounting a total of 89 hospitals and 25677 beds (DGS, August 2006).


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Project methodologies included:

- Research of papers and statistical analysis using SPSS.

- Use of a random sample of the data base (5% of all the data) in which the syntax would be previously designed.

- Selection of the four MDC (Major Diagnosis Categories), according to frequency and clinical relevance.

- After specifying the MDCs, recourse to the DRGs.


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Statistical analysis – variables and aims:

1) Demographic characteristics of the patients: age, gender.

2) Hospitalization’s causes and its temporal evolution, defining:

the main diagnosis (recurring either to DRG or MDC); the type of admission; the median time of hospitalization; the discharge destination.

3) Evaluation of hospital’s outcomes, appealing to: mortality; number of admissions; readmission due to the same previous causes or after

medical/surgical episode (within a period of 30 days).Faculty of Medicine – University of Porto

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Results- Four MDCs were selected according to their frequency and clinical significance. In spite of being frequent, two MDCs (MDC=14 and 15) were eliminated as they weren’t related with the purpose of the study. - Within each MDC, three DRGs were chosen based on the same criteria.

Categories Frequency Percent

1 (Nervous system) 17144 7

4 (Respiratory system) 19075 8

5 (Circulatory system) 22612 9

6 (Digestive system) 24114 10

Others 159170 66

Total 242115 100


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Results: nervous system demographic

indicators


DRGs selected

4%9%

31%56%

Cranitomy (>17) except for traumatism

Decompression of Carpic Tunel

Specific Brain-vascular pertubations

Others

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Results: nervous system hospitalization

profile

Readmissions

0

1000

2000

3000

4000

5000

6000

7000

No Yes


Type of Admission

0

1000

2000

3000

4000

5000

6000

7000

Programmed Not programmed

Specific Brain-vascularpertubations

Decompressionof Carpic Tunel

Cranitomy (>17)except fortraumatism

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Results: nervous system hospitalization

profile


Discharge Destination

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Specific Brain-vascular

pertubations

Cranitomy (>17)except for

traumatism

Decompression ofCarpic Tunel

Others

Death

Departure against thedoctor’s report

Hospital of NHS

Exterior (non specified)

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Results: nervous system hospital outcomes


Number of admissions

7830 8209

1105

0

2000

4000

6000

8000

10000

Central General district District level 1

Discharge destination

0

1000

2000

3000

4000

5000

6000

7000

8000

Exterior (nonspecified)

Hospital of NHS Mortality Other

Age

0

2000

4000

6000

8000

10000

12000

<=1 2 to 17 18 to 59 >60

District level 1

General district

Central

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Results: respiratory system demographic

indicatorsDGRs selected

40% 34%

15%11%

Pneumonia

Bronchitis & asthma

Chronic obstructivepulmonary disease

Other diseases

Gender

0

1000

2000

3000

4000

5000

6000

7000

Male Female


Age

0

1000

2000

3000

4000

5000

6000

7000

8000

<=1 2 to 17 18 to 59 >=60

17

Results: respiratory system hospitalization

profile



0

10

20

30

40

50

60

70

80

90

100

Exterior(non

specified)

Death Hospital ofNHS

Others

Pneumonia

Bronchitis & asthma

Chronic obstructivepulmonary disease

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Results: respiratory system hospital

outcomes



7305

10200

1570

0

2000

4000

6000

8000

10000

12000


Month of admission

0

500

1000

1500

2000

2500


0100020003000400050006000700080009000

Exterior (nonspecified)

Death Hospital of NHS Others

Central

General district

District level 1

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Results: circulatory system demographic

indicators

Gender

0

1000

2000

3000

4000

Masculine Feminine


DRGs selected

69%

15%

8%

8%

CardiacinsufficiencyMyocardialinfarctionPacemakerimplantOthers

Age

0

1000

2000

3000

4000

5000

6000

7000

<= 1 2 to 17 18 to 59 >60

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Results: circulatory system hospitalization

profile

Frequencies of readmissions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cardiacinsufficiency

Pacemakerimplant

Myocardialinfarction

Yes

No


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Results: circulatory system hospitalization

profile



0

10

20

30

40

50

60

70

80

90

100

Exterior(non

specified)

Hospital ofthe NHS

Domiciliaryservice

Departureagainstdoctor'sreport

Death

Pacemaker implant

Cardiac insufficiency

Myocardial infarction

Months

Frequency Percent

1 29 10,7

2 22 8,1

3 14 5,2

4 23 8,5

5 18 6,7

6 17 6,3

7 19 7,0

8 16 5,9

9 14 5,2

10 32 11,9

11 31 11,5

12 35 13,0

Total 270 100,0Mortality in myocardial infarction

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Results: circulatory system hospital

outcomes



10837 10628

1147

0

2000

4000

6000

8000

10000

12000


Gender

0

1000

2000

3000

4000

5000

6000

Masculine Feminine

Age

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

<=1 2 to 17 18 to 59 >60

Central hospital

General district hospital

District level 1 hospital

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Results: digestive system demographic

indicatorsDRGs selected

20%

12%

14%

54%

Hernia

Appendectomy

Oesophagitis andgastroenteritis

Others

Age

0

1000

2000

3000

4000

5000

<=1 2 to 17 18 to 59 >60


Gender

0

1000

2000

3000

4000

5000

6000

7000

Masculine Feminine

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Results: digestive system hospitalization

profile

Type of admission

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Programmed Not Programmed

Oesophagitis andgastroenteritis

Appendectomy

Hernia


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Results: digestive system hospital outcomes



8897

13419

1798

02000400060008000

10000120001400016000

1 2 3Central General district District level 1

Age

0

5

10

15

20

25

30

35

40

45

50

<=1 2 to 17 18 to 59 > 60

Type of admission

0

10

20

30

40

50

60

70

80

Programmed Not programmed "Acess program" PECLEC

Central hospital General district hospital District level 1 hospital

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Discussion


The major causes of admissions were related to disorders of the digestive, circulatory, respiratory and nervous system, affecting over 80000 people out of a total of over 240000.

Admissions at central hospitals were primarily due to circulatory disorders and at general district and district level 1 hospitals due to disorders of digestive system.

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Time of hospitalization - higher in respiratory disorders and lower in digestive disorders.

Readmissions - more frequent in respiratory disorders.

Mortality - higher in respiratory disorders.

Discharge destination- Hospital of NHS: respiratory disorders.

- Departure against doctor report: circulatory disorders

Gender - Men: digestive/circulatory/respiratory disorders

- Women: nervous disorders

Age - <= 1 and >=60: respiratory disorders

- 2 to 17 and 18 to 59: digestive disorders

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Central hospital General district hospital

District level 1 hospital

Readmissions due to nervous or digestive disorders were more frequent.

Presented the highest mortality for digestive disorders.

The transferences to other hospital of NHS were more frequent.

Readmissions due to circulatory disorders were more frequent.

Presented the highest mortality for circulatory, nervous and respiratory disorders.

Readmissions due to respiratory disorders were more frequent.

PECLEC showed a significant impact, particularly for circulatory and digestive disorders.

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Limitations of the study:

DRG system is used to previous payment to hospitals, leading frequently to an inadequate remuneration and therefore promoting the rejection of the most severe patients.

Difficulty in analysing the complexity of the different cases and in deciding which diagnosis suits better a particular patient.

Some indicators are built from the information of hospital data bases which is strongly dependent on the accuracy and rigour that each hospital dedicates to the retrieve and codification of its clinical information.

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The variable time of hospitalization can be misleading as some systems consider 1 day the period of time between 0-48h while others consider 1 day the period of time between 0-24h.

The data base didn’t have the identification of the episodes nor the patients and so it was impossible to ensure that readmission occurred due to the same previous causes or after a medical/surgical episode.

The utilization of type C classification of hospitals made our results easier to analyse but in counterpart had implied a reducing view of hospital reality.

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The unit of analysis was the hospitalization and so we could not infer anything about the patient profile.

As we analysed only six years of hospitalization we could not conclude anything relatively to the temporal evolution of the disorders.

As we focused only in 4 MDCs and 12 DRGs, this research study can not be seen as an exhaustive dissertation about the causes of admission.

As the private hospitals and those located in Azores and Madeira were excluded it was not possible to extrapolate our results to that population.

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Final consideration:

Hospitals across Europe have been changing considerably with more people being admitted but staying for shorter periods. In spite of being centres of health care, they also fulfil essential roles in teaching, research and cooperation with local communities.

Therefore, it is primordial to adapt the structures of each care unit to the population it serves, basing this approach on a long-term program of sustained and stable investment.

This study reported the major causes of admission in Portuguese public hospitals for six years and accomplished relevant results that may help in the restructuring of Portuguese health systems. Given the originality of this study, it is important to analyse the problem under other perspectives in order to build a robust model of Portuguese reality.

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Acknowledgements

- Altamiro da Costa Pereira, PhD, Professor FMUP

- Armando Teixeira-Pinto, PhD, Professor FMUP


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2006/2007

Class 8Adriana Lages

Ana Isabel RodriguesAna Rita Matos

Carla MaiaDiana Leite

Ezequiel SilvaHugo Sêco

Joana SimõesJorge Silva

Márcia LeiteMarta TeixeiraRaquel OliveiraSara Machado

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References:

[1] AVERILL, R.F. The design and development of the Diagnosis Related Groups. In: Health Systems International. Diagnosis Related Groups; second revision definitions manual. New Haven, Conn, 1985.

[2] DISMUKE, C.E.; SENA, V. Has DRG payment influenced the technical efficiency and productivity of diagnostic technologies in Portuguese public hospitals? An empirical analysis using parametric and non-parametric methods. Health Care Manag. Sci. 1999 May;2(2):107-16.

[3] FETTER, R.B.; FREEMAN, J.L.; AVERILL, R.F.; THOMPSON, J .D. Case-mix definition by Diagnosis Related Groups. Med. Care, 18:1-53, Feb. 1980.

[4] FETTER, R.B. Concepts of case-mix management. In Roger-France, F.H.; Moor, G. de; Hofdijk, J.; Jenkins, L., org. Diagnosis Related Groups in Europe. Ghent, Bélgica, Goff BVBA, 1989. p. 134-42.

[5] FREEMAN, J.L. DRG refinement project. In: International Conference on the Management and Financing of Hospital Services, 2nd, Sydney, 1988. Proceedings. Sydney, 1988. p. 128-33.

[6] PALMER, G.R.; FREEMAN, J.L.; FETTER, R.B.; MADOR, M. International comparisons of hospital usage: a study of nine countries, based on DRGs. New Haven, Health Systems Management Group. Yale School of Organization and Management, 1989.

[7] URBANO, J. & BENTES, M. Definição da produção do hospital: os Grupos de Diagnósticos Homogéneos. Rev. port. Saúde públ., Lisboa, 8 (1): 49-60, 1990.

[8] VERAS, C.T.; NORONHA, M.F.; MARTINS, M.S.; BRAGA NETO, F.C.; LEITE, I.C.; SILVER, L. Avaliação de métodos alternativos para racionalização e análise de qualidade nos serviços de saúde. Rio de Janeiro, Escola Nacional de Saúde Pública, FIOCRUZ, 1990.Faculty of Medicine – University of Porto

six years of hospitalization in portuguese public hospitals

Documents

central hospitals

general district hospitals

district hospitals level

previous causes

main diagnosis

hospitalized patients

drg system

data base