Fischer: Design Principles for an Inpatient Rehabilitation Patient Classification System.

Design Principles for an
Inpatient Rehabilitation Patient Classification System

Wolfram Fischer

Zentrum für Informatik und wirtschaftliche Medizin
CH-9116 Wolfertswil SG (Switzerland)
http://www.fischer-zim.ch/

In: Proceedings of the 13th PCS/E International Working Conference. Florence 1997:227-9.

ABSTRACT

Some reflections made at the beginning of a project for the development of a rehabilitation PCS are shown.

INTRODUCTION

In Switzerland awareness of cost containment is spreading quickly to all health sectors. The new law of public health insurance (Krankenversicherungsgesetz KVG, 1994) encourages new models of drawing up contracts. Prospective payment systems based on patient classification systems (PCS) like Diagnosis Related Groups (DRG) appear as very attractive models even though they are not beyond all doubts.

There are various attempts to classify rehabilitation patients: Functional Related Groups (FRG) [1], FRGs based on the Functional Independence Measure (FIM-FRG) [2] [3], Functional Impairment Groups (FIG) [4], a French study [5]. These studies show that the development of patient classification systems in the rehabilitation setting forces one to reconsider the design principles of conventional patient classification systems as used in the acute setting. (As for the rest, this is true also in other sub-acute and non-acute settings.)

I will talk about some reflections we made at the start of a PCS project for inpatient medical rehabilitation treatment.

METHOD/THEORETICAL BACKGROUND

The Product of Rehabilitation Services

PCSs are trying to describe products of health services. To define a product for the health care market you must have:

When asking persons doing rehabilitation about their product there is no quick answer. The "delivery process" is developing and changing in the course of time. This evolution over time is an essential aspect of rehabilitation services.

Entities of Treatment

One of the very first questions is: How to get entities of treatment that can be seen as product resp. contract entities?

Could it be a hospital case or a sort of illness episode? The fact that rehabilitation patients suffer from chronic diseases implies that the target is not that hospital cases must be as short as possible; rather, the treatment ought to help the patients to live independently as far as possible at low treatment costs over a long period of time.

Consequently we have to search for an appropriate definition of episodes. The straightforward definition would be: An episode lasts from the beginning to the end of the illness. In rehabilitation this is inoperable as it would also be in analysing other chronic diseases. But there are two dimensions which can be taken into account:

Phases Treatment Segments	Diagnostics	Therapy	Follow Up	Waiting
Initialization	s
Prevention	s	(e)
Acute Care	E	E	(e)	(e)
Rehabilitation	E	E	(e)	(e)
Nursing	s	(e)		E
Treatment Pause				s

Legend:

E	is an essential treatment phase of a treatment segment
s	is normally carried out in a simplified version
(e)	occurs intermittently

Classification Criteria:
Patient Characteristics, Treatment Characteristics and Goals

The whole work of searching relevant classification criteria is simplified through strictly separating patient characteristics (states) and treatment characteristics (actions). [7]

States can be described by using attributes and values which enable one to analyse changes. Actions generate costs; therefore they should be used as dependent variables.

Ideally the independent variables (the classification criteria) are taken only from the list of patient characteristics which are conditions, resources of the patient, health potential, possibly also prognosis, risks and chances. This works if the treatment goals can be derived from the patient characteristics. If - after having obtained knowledge of the patient characteristics - there must be a decision about the treatment goals, then these have to be added separately to the classification criteria. This is the normal case in the rehabilitation setting. In sum, the independent variables should be chosen in a manner that they are able to specify the need of treatment.

To describe the conditions, the frame of ICIDH is suitable. It proposes to assess - beyond the diagnoses - the manifestions of the diseases as: [8]

RESULTS

Design Principles

The following design principles for the construction of an inpatient rehabilitation PCS were proposed:

(1) There is a strict separation of patient characteristics (states) and treatment characteristics (actions).

(2) Patient characteristics do not only consist of diagnoses; impairments, disabilities and social handicaps determine the treatment as well.

(3) Patient characteristics change in the course of time. They have to be assessed more than once during a hospital stay.

(4) Rehabilitation goals which depend on the resources and the rehabilitation potential (health potential) of the patient are further determining factors for the treatment.

(5) There must be a certain consensus between provider and purchaser/society/patient about the best or appropriate treatment practice. This will be addressed by treatment guidelines to be developed.

(6) A rehabilitation treatment requires certain capabilities of the rehabilitation institute. This will be addressed by an accreditation strategy.

(7) Instead of speaking of a case, treatment segments and within them treatment phases are to consider. The minimum entity which can be analysed is a week. The contract entity can be a day.

Treatment Segments and Treatment Phases

The essential treatment phases to subgroup the rehabilitation treatment segments are:

Potential Classification Criteria

A conventional Minimum Basic Data Set containing mainly diagnoses and procedures as classification variables is insufficient in the sense that it does not contain most of the relevant cost driving criteria. In consequence the following indicators for the need of treatment were evaluated in the first survey: main rehabilitation diagnostic groups, impairment, disability (mainly functional independence measured by the FIM™ instrument) [9] with additional assessements in order to refine lower and upper edge zones), selected social burdens, description of the rehabilitation treatment segment, the main rehabilitation goals, the main rehabilitation obstacles. (The main rehabilitation goals can be related to disabilities, impairments or social handicaps. This will make possible to emphasize the importance of the corresponding variables as classification criteria.)

As dependent variables nursing and therapeutic times are collected for each day in order to calculate variable costs and to construct typical ways of treatment.

CONCLUSION

To describe products of health services, I have mentioned that we must have a label, a price and a description.

According to our proceeding we will first have a description consisting of the classification criteria and hopefully a way of treatment of not too big variability derived from the measurement of nursing and therapeutic interventions and times. The quality facets will be brought in by establishing guidelines and accreditation criteria. We must be aware that the change in functional status (CFS) is not always a justifiable measure and incentive for efficient care. E.g. there has to be a consensus that providing first treatment of a certain number of weeks for a patient in coma is justified also if this results in no change of functional status. It is justified just because there is some chance that an improvement will take place. But all know that the improvement for one specific patient is not predictable most of the time.

The cost calculations for nursing and therapy have to be completed by a fixed amount per diem for all other running costs. This will be the basis to propose prices.

The label will be a summary of the classification criteria which should have a clinical meaning.

REFERENCES

[1] Harada N, Kominski G, Sofaer S: Development of a Resource-based Classification Scheme for Rehabilitation. Inquiry 30:54-63, 1993.

[2] Stineman M, Escarce JJ, Goin JE, Hamilton BB, Granger CV, Williams SV: A Case-Mix Classification System for Medical Rehabilitation. Medical Care 32:366-79, 1994.

[3] Stineman MG, Hamilton BB, Granger CV, Goin JE, Escarce JJ, Williams SV: Four methodes for characterizing disability in the formation of function related groups. Arch-Phys-Med-Rehabil 75:1277-83, 1994.

[4] Webster F: The Development of a Casemix Classification System for Inpatient Rehabilitation Services. Stage 1 of the Victorian Rehabilitation Project. In: Commonwealth of Australia, 7th Casemix Conference 95:151-5.

[5] Trombert-Paviot B, Verin I, Gautheron V, Rodrigues JM: Development of a Casemix Classification System for Inpatient Medical Rehabilitation: A French Pilot Study. In: Commonwealth of Australia, 8th Casemix Conference 96:71-7.

[6] Fischer W: Patientenklassifikationssysteme zur Bildung von Behandlungsfallgruppen im stationären Bereich - Prinzipien und Beispiele (Patient Classification Systems for Grouping Hospital Cases - Principles and Examples). BSV and Z/I/M, Bern and Wolfertswil 1997: 60.

[7] Fischer W: PCS and Casemix Types. In: Proceedings of the 11th PCS/E International Working Conference. Oslo, 1995:50-7.

[8] WHO: ICIDH: International Classification of Impairments, Disabilities, and Handicaps; Teil 1: Die ICIDH - Bedeutung und Perspektiven; Teil 2: Internationale Klassifikation der Schädigungen, Fähigkeitsstörungen und Beeinträchtigungen - Ein Handbuch zur Klassifikation der Folgeerscheinungen der Erkrankung. Ullstein Mosby, Berlin Wiesbaden 1995.

[9] Granger CV, Brownscheidle CM: Outcome Measurement in Medical Rehabilitation. International Journal of Technology Assessement in Health Care 11:262-8,1995.

Previous Paper:	Tables of Contents:	Next Paper:
Cost Weight Proportions	English Papers	Multidimensional PCS
	Navigations-Tabellen
	Z I M - Hauptseite