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Table 1: Showing the top 5 DRG groups ranked by median cost, per episodes for each DRG for the 2008-2009 financial year and the percentage of allied health contact for each staff group. Cells that are filled in gold indicate range above median and those in red are those with values above the upper quartile. RESULTS The amount of episodes for each of the top three DRG groups were then plotted onto area proportional Venn diagrams [5] to highlight and identify potential areas for interdisciplinary practice and additional factors like number of contacts per group and length of time to first contact calculated and graphed below. Targeting interdisciplinary practice: Using allied health activity data to show patterns of care delivery between professions within high use diagnostic related groups. Nathan Billing, Waitemata District Health Board, [email protected] BACKGROUND Allied health staff routinely collect activity data and have been estimated to provide 15 to 20% of all patient care service in hospitals is provided by allied health practitioners.[1]. This activity information and diagnostic related group (DRG) costing information is readily available data, and has been suggested that it can have a role to play in helping identify potential cost saving measures for allied health [2]. The DRG system was designed to group together acute in patients who are similar clinically and who have a similar pattern of resource use. They provide a clinically meaningful way of relating the number and types of patients treated to the resource provided. They are developed from diagnostic, procedure, and demographic information routinely available from a hospital inpatient medical record on discharge [3]. Because DRGs are grounded on a medical/illness perspective and a procedure-based system there is widespread belief that it is unsatisfactory in describing and predicting the activity of allied health professions in health care service delivery[4]. However, there has been little research into the potential use of DRG codes in conjunction with allied health activity data to show areas where there may be a need to improve interdisciplinary practice to streamline patient care within high cost DRG groups known to also have a high level of allied health input. References 1. Boyce R. Internal Market Reforms of Health Care Systems and the Allied Health Professions: An International Perspective. International Journal of Health Planning and Management 1993; 8(3): 201-217. 2. Billing N, Beaumont R, Cornforth B, Ayar Z, Orr M (2011) Utilizing Allied Health Activity Data to Investigate Concordance/Discrepancy Between AHP Cost and DRG Payment. Submitted to HCIRO for publication and presented at HINZ annual conference Available at: http://www.hinz.org.nz/uploads/file/2011conference/P16_Billing.pdf (Accessed 20 April 2012). 3. Fetter RB. Casemix classification systems. Australian Health Review, 1999; 22(2), pp.16-38 4. Cleak H. A model of social work classification in health care. Australian Social Work. 2002; 55(1):38-49. 5. University of Kent, eulerAPE: Drawing area proportional Euler and Venn Diagrams Using ellipses. (2012) [Online] Available at: http://www.eulerdiagrams.org/eulerAPE/ (Accessed 22 April 2012). 6. Byron AL, McCathie CF.Casemix: Moving forward. Casemix: the allied health response. Medical Journal of Australia. 1998; 169: S46-47. http://www.mja.com.au/public/issues/oct19/casemix/byron/byron.html (Accessed 30 March 2012). Acknowledgement: This data was initially obtained as part of my masters dissertation and data would have not been available without the support of Tamzin Brott, HOD allied health, Brett Cornforth & Zina Ayar, Decision support, Waitemata District Health Board Graphs were plotted making use of software from the University of Kent called Rank DRG Description # of episode s Occupational Therapy Physiotherapy Speech and Language Therapy Social Work Dietetic Median Top quartile 1 B70A: Stroke With Catastrophic Complications C (Median cost =$10 315.23/episode) 167 71.9% 83.8% 79.6% 41.9% 42.5% 57.2% 71.5% 2 Z60A: Rehabilitation With Catastrophic or Severe Complications ($9101.72/episode) 1412 1.4% 1.9% 5.5% 3.4% 39.0% 2.7% 3.3% 3 E62A: Respiratory Infections/Inflammations With Catastrophic Complications C ($6908.78/episode) 280 27.5% 55.7% 22.1% 27.9% 36.1% 27.7% 34.6% 4 B70B: Stroke With Severe Complications C ($5532.81/episode) 232 59.1% 67.7% 46.1% 27.2% 13.8% 36.6% 45.8% 5 E65A: Chronic Obstructive Airways Disease With Catastrophic or Severe Complications C($4222.37/episode) 524 24.5% 50.6% 3.6% 23.8% 18.7% 21.3% 26.6% 0.0 1.0 2.0 3.0 4.0 5.0 B70A Z60A E62A Number of days Graph 1: Median length of time till first contact Dietetic Occupational Therapy Physiotherapy Social Work Speech and Language Therapy Allied health group with first contact OBJECTIVE To use allied health activity data to retrospectively compare and contrast difference in care delivery activity between professional groups for the diagnostic related groups (DRG) with high allied health input to signal areas where interdisciplinary practice could be encouraged. METHOD Allied health intensive DRG’s were identified by using the hospital costing account system. By allocating the sum of all allied health related cost centres to each DRG group, (for the 2008-2009 financial year at WDHB), the DRG groups that had the largest total allied health cost attributed to them were identified [2]. The top ten DRG groups, by total allied health cost, were then ranked and all the episode numbers for each of these DRG groups were obtained. These were then used to look up all the allied health activity data for each allied health discipline (i.e. Dietetics, Occupational Therapy, Physiotherapy, Speech and Language Therapy, and Social Work). This allied health activity data was then merged with the DRG related information (e.g. Admission and separation / discharge dates) [2]. As the input of five allied health staff groups are being investigated, and given that each group may provide input to patients within each episode independent of one another, the number of potential combinations of staff per episode is large. In order to identify which staff groups played an important role in each DRG group, the percentage of allied health contact for each staff group was calculated, and median of these was then used to highlight which staff groups appeared to have more input than others for each DRG group. In order to avoid information overload, the median actual cost per episode (sum of all charges for each episode) was calculated for each DRG group and the top three DRG groups selected. These three DRG’s represent high cost episodes for the hospital areas where better interdisciplinary practice may improve efficiencies. These top 5 DRG groups can be seen in Table 1 below. DISCUSSION After discussion with colleagues it was found that all serious stroke (B70A) patients are automatically referred to Physiotherapist, SLT and occupational therapist by medical teams. This may be the reason why dietitian input was not initially identified as a staff group that provides a meaningful input when percentage contacts were used. Scaled Venn diagrams clearly highlight areas where closer working between groups should be considered. Also potentially highlight areas where follow up guidelines may be required. E.g. very large dietetic input into Z60A DRG group and a high number of contacts per episode, may need to be investigated further. For the staff groups identified with the shortest time span to first contact, they could potentially refer on to other allied health professionals as appropriate to improve their response time. In order for more meaningful analysis of allied activity data it would be useful to capture the time patients were referred and whether or not the referral was appropriate. Because DRG case-mix data does not capture allied health work that well as much allied health work is often determined by reasons not directly related to the principal cause for admission [6]. For instance, treatment of malnutrition by dieticians could be ‘secondarily’ associated with many DRGs. 0 2 4 6 8 B70A Z60A E62A Number of contacts Graph 2: median number of contacts per episode *Most contacts per episode but % dietetic input not highlighted in B70A 0.00 50.00 100.00 150.00 200.00 250.00 300.00 B70A Z60A E62A Number of minutes Graph 3: Median total contact time per episode LIMITATIONS / ISSUES Using Median of Allied health contact: Each DRG group would have different AHP needs and Graph 2-3 suggest Dietetic input may have had more of a role to play in B70A then social work. Secondary data analysis: The DRG grouping system was not designed for analysing potential allied health efficiency issues. Length of time till first contact does not take into capture when referred or if appropriate. Timeliness: Activity data used for this analysis is already >3 years old Multiple admissions: Episodes do not account for multiple patient admissions. Statistical analysis: Was not performed to determine significance of certain staff combinations on Length of stay (LOS) as not all information available *Same contact time as SLT, but % dietetic input not highlighted
