Z I M - Paper 11th PCS/E Oslo

Sept. 1995

Contents :  •  Abstract  •  Introduction  •  Proposal  •  Discussion  •  Conclusions  •  References

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ABSTRACT

With this kind of thinking it will be possible to use the same conceptual structures to describe all types of states.

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INTRODUCTION

It is commonly accepted that we construct categories of patients characterized either by diagnoses or by treatment procedures. We investigate many efforts to differentiate patient categories derived from diagnoses and/or treatment procedures to get homogeneous groups in relation to resource use. [1] [2] [3] [4]

The aim of these efforts is to increase the variance reduction (VR). It is only marginally reached. [5]

We need to "re-engineer" our ideas about criteria for patient categorization.

There have been some promising researches which try to implement new ideas. Duwel et al. in the Netherlands define criteria that make the medical decisions explicit in a prospective way. Criteria on the somatic axis are complaints of the patient and complaints to be treated, working diagnosis (hypothesis) and others. Additional criteria are considered for the psychosocial, environmental and demographic axes. [6] At the NCMO/UK Sanderson and his crew try to separate resource groups from need groups. [7] [8] My ensuing proposal was stimulated by this approach. Ivarsson et al. from Sweden had set up State Related Groups to show that a certain type of treatment is not work that necessarily leads immediately or in all cases to an end result, but that a treatment is a way to get from one patient state to a further patient state. [9] In Switzerland we are constructing a model that is based on two axes: a domain axis on which we distinguish between criteria coming from the medical, nursing or social point of view, and an axis which differentiates between the distinct decision and execution levels, mainly: problems, goals and treatments. We have not yet tried to add to these levels a level for results. [10] [11] [12] [13]

In this paper I want to describe a conceptual grid which could serve as a basic structure for the description of existing and the development of new approaches to patient classification.

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PROPOSAL

Grouping Hierarchy

To have a conceptual grid I propose to speak about the following kinds of groupings:  
 

  ·-----------·
  | Condition |
  | Groups    |
  ·-----------·
        |
        V
  ·-----------·
  | Need      |
  | Groups    |----------·
  ·-----------·          |
        |                |
        V                V
  ·-----------·     ·---------·
  | Resource  |     | Outcome |
  | Groups    | --> | Groups  |
  ·-----------·     ·---------·  

Table 1: PCS and Casemix Types

Condition Groups

Condition groups are groups of patients with similiar health related problems. Condition groups are based only on patient characteristics. They include:

• Patient health related problems. (Staged diagnoses describing causes and pathology (like [14] [15]); disabilities and handicaps (e.g. [16]); interfering social conditions.)
• Possibly resources of the patient. (That is an important point in setting up a nursing plan, but there are no generally accepted systems of criteria available. [17])
• Expectations of the patient. (Perhaps the patient does not want to be treated in respect to some problems!)

Need Groups

Need groups are groups of patients, which require similar packages of care They are condition groups combined with objectives of care. They are to set up based on the most important indications which lead to a specific treatment.

A differentiation of need groups according to the different phases of treatment seems to be appropriate.

Phases of treatment are: [12]

• diagnostic phase
• treatment phase
• post treatment care (inpatient or outpatient)
• rehabilitation phase (not always done with professional assistance)

A differentiation of each "case" in treatment phases is especially useful in health care systems where different providers are allowed to offer various pieces of treatment paths, e.g. when the diagnostic procedures can be performed inside or outside the hospital.

In a modular PCS - a PCS in which a patient can be assigned to one or more groups (e.g. like PMCs [4] [11]) - it could be interesting to combine several therapeutic need groups with the same diagnostic need group.

Resource Groups

Resource groups categorize packages of care: Resource groups are primarily split up according to condition and need groups and then further differentiated by treatment characteristics.

To describe their work this way is acceptable to many surgeons. Coding systems for surgical procedures are used everywhere (e.g. ICD-9-CM, Vol. 3, or ICPM).

Problems are arising when one tries to describe medical procedures. Existing coding systems consider these procedures only marginally; commonly used PCS are based - in addition to diagnoses - nearly exclusively on surgical procedures.

Nursing PCS are often based on resource groups: They describe patients primarily on grounds of nursing procedures. [17]

Outcome Groups

Outcome groups categorize results of care in dependence on conditions and objectives and/or treatments.

Outcome groups can be the condition groups of an immediately ensuing treatment cycle. The need of additional treatment - e.g. in the rehabilitation phase - is based on the outcome of the current treatment.

To describe outcome groups is the most difficult point. What was really the outcome? But I think if we can describe health related problems we should also try to say if, or at least to what extent, these problems have disappeared.

We speak of a "discharge diagnosis". And we mean: The problem from which the patient suffered at the beginning of or during hospitalisation as we discovered it during the treatment. But the discharge diagnosis is not the problem remaining at the time of discharge. Actually we do not know if or how the problem remains at the time of discharge.

A way to explain more clearly is to think in terms of states which are described by attributes and values.

States

Criteria which are commonly used to describe patients can be seen as different types of states:

1. A condition/ diagnosis/problem is a current state.
2. A prognosis is an expected state.
3. A objective (goal, aim) is a state aimed at.
4. A result is an achieved state.
5. (A treatment is a transition from one state to a further state.)

Table 2: Patient States

To describe states we can use attributes and values, such as: "sleep patterns" "severely disturbed"; "humerus" "multiple open fracture with involved joint"; "hypertension" "moderate (X-Y mmHg)" and so forth.

Henceforth a diagnosis should not only be a statement as to whether a certain condition is present or not. But we should state to what extent the condition is present and relevant. An approach of this kind is made in PCS that use severity levels like Disease Staging [14] [15] or Computerized Severity Index. [18]

If we manage to do that with diagnosis, we can also describe results in the same manner: Results are diagnoses made topical at the end of the treatment phase - or new diagnoses, as if the patient went to another provider for new treatment. An approach of this kind is made in the Omaha System (for Community Health Nursing)[19]: The result is measured on the "Problem Rating Scale for Outcomes" as the progress of each patient problem expressed in terms of the status of the problem, the knowledge and the behaviour of the patient concerning his problems. The values for status, knowledge and behaviour are measured on a five-point Likert-type scale (see table).

Objectives of care can be judged (a) in comparison with the prognosis and (b) in comparison with the results.  
 

Table 3: Example of state values:
The Problem Scale for Outcomes of the Omaha System for Community Health Nursing

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DISCUSSION

On the basis of the proposed levels of grouping and using the description model of states, we could define refined classification criteria. E.g. it would be possible to use diagnoses to describe the current state and results to determine the achieved changement.

If need groups are set up according to the most important indications which lead to a specific treatment, they could serve as a common acceptable grouping principle: Such groups will then justify a specific treatment and are therefore acceptable to physicians. Such groups cannot be so easily manipulated because they proceed from patient characteristics.

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CONCLUSIONS

To clarify discussions between purchasers and providers we might use a grouping concept which distinguishes different grouping levels.

Treatment criteria such as surgical procedures are more likely to be accepted by physicians as a basis of a PCS, than patient criteria (e.g. diagnoses). That was one reason for the choice of a hospital remuneration system in Germany which is based on procedures. [20]

But purchasers are more interested in condition groups or need groups. That was a starting idea for the efforts in the UK to combine condition groups and treatment groups in a matrix. [7]

By describing need groups, objectives of care must be discussed. There is a chance to bring in ethical issues which should be able to counterweight too narrow-minded economic reasoning, thus enabling one to show responsibility in a humane way also.

To view grouping concepts on different levels such as conditions, needs, treatments and results will help to clarify discussions between purchasers and providers.

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REFERENCES

[1] Mullin B: Refinement of the Medicare DRG to incorporate a measure of severity. Keynote address at the 10th PCS/E International Working Conference. Budapest 1994.

[2] Vertrees JC, Pollatsek JS: Measuring the ability of new types of DRGs to capture differences in severity of illness across hospital types. In: 9th International PCS/E Working Conference, Proceedings Vol I, München 1993:34-45.

[3] Averill R: Organisation of data collection and analysis using DRGs in USA. In: Roger France FH, Laires M [Eds.]: Communication of Health Care Resource Management Data in Europe - Recommendations of the Limelette Conference 1992, Bruxelles 1994 (Commission of the EU, XIII C-4: Telematics applied to healthcare):101-18.

[4] The Pittsburgh Research Institute: Patient Management Categories - A Comprehensive Overview. Pittsburgh 1993: 65 pp.

[5] Fischer W: DRG Development: Considering Severity of Illness. Streiflicht (Z/I/M) 1994/10-11: 1 p (in German).

[6] Duwel CMB, Kruijssen DACM: A Draft for a Hybrid Multi-Axial System to Classify Cardiological Patients. In: Proceedings of the 10th PCS/E International Working Conference. Budapest, 1994:216-21.

[7] Sanderson H: HRG Version 2 and Costing for contracting. In: Proceedings of the 10th PCS/E International Working Conference. Budapest, 1994:146ff.

[8] Prakash S: A methodology for the HBG project (HBG Sub-Project 4B. Report - part I). Winchester 12.12.1994 (HCMO).

[9] Ivarsson B, Lindmark J, Håkansson S: "State Related Groups", an all-setting psychiatric patient classification system - demonstration of preliminary work illustrated with an outpatient material. In: 9th International PCS/E Working Conference, Proceedings Vol I, Munich 1993:168-90.

[10] Kantonsspital Aarau: A Model to Cost Cases for the Hospital of Aarau. Aarau 1995 (in preparation; in German).

[11] Fischer W: Construction Principles of "Patient Management Categories" (PMC). In [10]: 26 pp.

[12] Fischer W: Possibilites of Performance Measurement in Hospitals. Bern 1994 (in German and in French): 200 pp.

[13] Fischer W: Proposal for a Structure of Minimal Data Sets for a Need Oriented Management of Health Institutions. In: Abstracts of the 10th Conference of the Swiss Society for Medical Informatics Geneva 1995:81-84 (in German).

[14] Gonella JS, Hornbrook MC, Louis DZ: Staging of Disease. A Case-Mix Measurement.. In: JAMA 1984(251)5:637-44.

[15] Gonella JS, Louis DZ, Marvin EG: Disease Staging: Clinical Criteria. Fourth Edition, Ann Arbor 1994 (MEDSTAT Systems).

[16] WHO: ICIDH - International Classification of Impairments, Disabilities, and Handicaps. Berlin Wiesbaden 1995 (Ullstein Mosby).

[17] Fischer W: Performance Measures and Patient Categorization Systems in Nursing - A Survey. Aarau 1995 (VESKA): 124 pp (in German).

[18] Horn SD, Gassaway JV, Horn RA: CSI: Computerized Severity Index: It's Uses and Application. In: PCS-News 1992/9/Okt:3-9+20.

[19] Martin KS, Scheet NJ: The Omaha System. A Pocket Guide for Community Health Nursing. Philadelphia 1992 (Saunders):35ff.

[20] Neubauer G: Building up a Performance Related Hospital Remuneration System - First Results of the German Model. In: Proceedings of the 10th PCS/E International Working Conference. Budapest, 1994:168-73.

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