Six years of hospitalizationSix years of hospitalizationin Portuguese public in Portuguese public
hospitalshospitalsAn analysis of the major causes of admission
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Structure
Discussion
Results Methods
Introduction
Purposes
Researchwork
Faculty of Medicine – University of Porto
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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).
Faculty of Medicine – University of Porto
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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
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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
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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
Faculty of Medicine – University of Porto
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
Faculty of Medicine – University of Porto
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
Faculty of Medicine – University of Porto
Age
0
1000
2000
3000
4000
5000
6000
7000
8000
<=1 2 to 17 18 to 59 >=60
17
Results: respiratory system hospitalization
profile
Faculty of Medicine – University of Porto
Discharge destination
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
Faculty of Medicine – University of Porto
Number of admissions
7305
10200
1570
0
2000
4000
6000
8000
10000
12000
Central General district District level 1
Month of admission
0
500
1000
1500
2000
2500
Discharge destination
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
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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
Faculty of Medicine – University of Porto
Discharge destination
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
Faculty of Medicine – University of Porto
Number of admissions
10837 10628
1147
0
2000
4000
6000
8000
10000
12000
Central General district District level 1
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
Faculty of Medicine – University of Porto
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
Faculty of Medicine – University of Porto
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Results: digestive system hospital outcomes
Faculty of Medicine – University of Porto
Number of admissions
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
Faculty of Medicine – University of Porto
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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Faculty of Medicine – University of Porto
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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Faculty of Medicine – University of Porto
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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Faculty of Medicine – University of Porto
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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Faculty of Medicine – University of Porto
Limitations of the study:
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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Faculty of Medicine – University of Porto
Limitations of the study:
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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Faculty of Medicine – University of Porto
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