Age and Ageing Advance Access originally published online on June 14, 2007
Age and Ageing 2007 36(4):472-473; doi:10.1093/ageing/afm053
Disability, clinical complexity, and diagnosis-related groups in old patients
SIR—We read with great interest the important paper by Carpenter et al. on the relationship between physical disability, length of stay, and diagnosis-related group (DRG) reimbursement in hospitalised people [1].We would like to contribute to the discussion on this topic presenting data obtained in 4,094 elderly patients (female = 61.5%, mean age = 79.4 ± 7.8 years) consecutively admitted to our ward. Our ward is modeled on the US ACE units [2, 3] and 78% of our patients are admitted through the emergency room.
A multidimensional evaluation, including information on demographics, cognitive and affective status, physical health, functional abilities, and social support was performed on the first day after admission using a standard protocol, by a trained staff of geriatricians. Physiological severity was computed using the Apache II score taking into account the degree of abnormality of multiple physiological variables, age and chronic coexistent conditions (e.g. CHF, COPD, cirrhosis, renal failure, and cancer) [4]. Self-reported disability in basic activities of daily living (BADL) was assessed using the Barthel Index (BI) [5]. Seven different levels of disability were considered.
As shown in Figure 1, a decrease of BI score detected on admission paralleled an increase in APACHE II score and DRG weight.
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Our data showed that the DRG values take in consideration the elderly patients' functional status, in line with the well-known strict correlation between disease and disability in old patients.
Furthermore our data indicated that disability is correlated with APACHE II score, an indicator of disease severity, suggesting a possible pathway ‘disease severity–disability–DRG weight’, in which function is a bridge between the biological alterations induced by pathological events and the reimbursement system groups.
In our setting the increase of the DRG weight reflected the appropriateness of hospitalisation since it paralleled the increase in disability and in disease severity. At the same time, this correlation confirmed the accuracy of DRG weight in reflecting the costs induced by clinical complexity in acute care settings, where length of stay (LOS) does not seem to play a significant role in costs (in our sample it is 6.5 days). Moreover, length of stay may also explain the differences we observed between our results and the results of Carpenter et al. [1] where the LOS was 14 days. In fact, in settings performing both acute and most of the rehabilitation care, the cost differences, induced by various disability levels, are more pronounced. This requires correction of the DRG weights at variance with acute care, where the strong relationship between disease and disability shows that the disease plays the most important role in cost determination.
1 Department of Internal Medicine and Geriatrics, Poliambulanza Hospital, Brescia and Geriatric Research Group, Brescia, Italy
2 University Unit, Geriatric Department, Ullevaal University Hospital, Oslo, Norway
* To whom correspondence should be addressed Email: rozzini-renzo{at}poliambulanza.it
References
- Carpenter I, Bobby J, Kulinskaya E, Seymour G. People admitted to hospital with physical disability have increased length of stay: implications for diagnosis related group re-imbursement in England. Age Ageing (2007) 36:73–8.
[Abstract/Free Full Text] - Rozzini R, Sabatini T, Trabucchi M. Geriatric wards in acute hospitals. Age Ageing (2005) 34:195–6.
[Free Full Text] - Palmer RM, Landefeld CS, Kresevic DM, Kowal J. A medical unit for the acute care of the elderly. J Am Geriatr Soc (1994) 42:545–52.[Web of Science][Medline]
- Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med (1985) 13:818–29.[Web of Science][Medline]
- Mahoney FI, Barthel D. Functional evaluation: the Barthel Index. Md State Med J (1965) 14:56–61.[Medline]
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