eMJA Casemix Supplement: Transferred patients - more complex and more costly?

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Casemix: moving forward

Transferred patients -- more complex and more costly?

Warwick W Butt and Frank A Shann

MJA 1998; 169: S42-S43

Synopsis - Introduction - Definitions of transfer status - References - Authors' details

Synopsis

AN-DRGs have some splits which take illness severity and complexity into account. Age is also often used as a proxy for severity of illness.

The need to transfer a patient may be a marker of illness severity or complexity and therefore resource utilisation. This is supported by studies of patients transferred to intensive care units.

Data on the costs and outcomes of all transferred patients should be collected; depending on the results, refinements of DRGs may be indicated.

Introduction
Greater accuracy of DRG classification would result in more appropriate healthcare funding. A limited number of complications and comorbidity splits in AN-DRGs take into account illness severity and complexity. In addition, age, in both young and old patients, is often used as a proxy for illness severity. DRG accuracy could be further improved, if other easily applied measures of illness severity could be identified.
Patients transferred from one hospital to another because they require specialised treatment may represent a different patient population to those not transferred. A recent study has shown the differential resource utilisation of different populations, with hospital care for Aboriginal and Torres Strait Islander patients estimated to cost 30% more than that for non-Aboriginal and Torres Strait Islander patients with a similar DRG classification¹(see Fisher et al). It is possible that hospital care for transferred patients may also be more costly, because being transferred may be a marker for illness severity or complexity and therefore resource utilisation.
Summaries of studies of comparative costs of transferred and non-transferred patients are shown in the Box. The studies indicate that transferred patients generally are sicker, use more resources, have a longer length of hospital stay and an increased risk of death. Costs may be higher, particularly if death occurs after a long illness. Most of the currently available data relate to patients transferred to intensive care units.
Definitions of transfer status
To apply a patient's transfer status as a measure of severity, definitions need to be standardised. We propose the following categories:
Referral: Transfer of a patient to a different hospital for a particular doctor's opinion.

Up transfer: Transfer of a patient to another hospital for inpatient specialist treatment not available at the primary hospital.

Down transfer: Either return transfer of an inpatient to the primary hospital, or transfer of a patient to another hospital for recovery.

Sideways transfer: Transfer of a patient to another hospital, because the required facilities at the referring hospital are fully occupied.

Further Australian data will need to be collected prospectively on the costs and outcomes of patients who are transferred from one hospital to another for specific, complex treatment. In the light of these results, further analysis of transfer status will be needed, before it can be applied as a measure of illness severity and resource utilisation. Depending on these results, refinements of DRGs may then be indicated.

References

Commonwealth Department of Health and Family Services. Report on National Aboriginal and Torres Strait Islander Casemix Study. Adelaide: Brewerton and Associates Pty Ltd, April 1997.
Munoz E, Soldano R, Gross H, et al. Diagnosis related groups and the transfer of general surgical patients between hospitals. Arch Surg 1998; 123: 68-72.
Jencks SF, Bobula JD. Does receiving referral and transfer patients make hospitals expensive? Med Care 1988; 26: 948-958.
Pon S, Notterman DA, Kathryn M. Pediatric critical care and hospital costs under reimbursement by diagnosis-related group: effect of clinical and demographic characteristics. J Pediatr 1993; 123: 355-364.
Borlase BC, Baxter JK, Kenny PR, et al. Elective intrahospital admissions versus acute interhospital transfers to a surgical intensive care unit: cost and outcome prediction. J Trauma 1991; 31: 915-918.

Authors' details
Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC.
Warwick W Butt, MD, FRACP, Staff Specialist in Intensive Care.
Frank A Shann, MD, FRACP, Director of Intensive Care; and Professor of Critical Care Medicine, University of Melbourne, Melbourne.
Reprints will not be available from the authors.
Correspondence: Dr W Butt, Intensive Care Unit, Royal Children's Hospital, Flemington Parade, Parkville, VIC 3052.
E-mail: buttwATcryptic.rch.unimelb.edu.au

Go to the next article . . .
Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company.
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".
<URL: http://www.mja.com.au/> © 1998 Medical Journal of Australia.

Synopsis
	AN-DRGs have some splits which take illness severity and complexity into account. Age is also often used as a proxy for severity of illness. The need to transfer a patient may be a marker of illness severity or complexity and therefore resource utilisation. This is supported by studies of patients transferred to intensive care units. Data on the costs and outcomes of all transferred patients should be collected; depending on the results, refinements of DRGs may be indicated.
Introduction
	Greater accuracy of DRG classification would result in more appropriate healthcare funding. A limited number of complications and comorbidity splits in AN-DRGs take into account illness severity and complexity. In addition, age, in both young and old patients, is often used as a proxy for illness severity. DRG accuracy could be further improved, if other easily applied measures of illness severity could be identified. Patients transferred from one hospital to another because they require specialised treatment may represent a different patient population to those not transferred. A recent study has shown the differential resource utilisation of different populations, with hospital care for Aboriginal and Torres Strait Islander patients estimated to cost 30% more than that for non-Aboriginal and Torres Strait Islander patients with a similar DRG classification¹(see Fisher et al). It is possible that hospital care for transferred patients may also be more costly, because being transferred may be a marker for illness severity or complexity and therefore resource utilisation. Summaries of studies of comparative costs of transferred and non-transferred patients are shown in the Box. The studies indicate that transferred patients generally are sicker, use more resources, have a longer length of hospital stay and an increased risk of death. Costs may be higher, particularly if death occurs after a long illness. Most of the currently available data relate to patients transferred to intensive care units.
Definitions of transfer status
	To apply a patient's transfer status as a measure of severity, definitions need to be standardised. We propose the following categories: Referral: Transfer of a patient to a different hospital for a particular doctor's opinion. Up transfer: Transfer of a patient to another hospital for inpatient specialist treatment not available at the primary hospital. Down transfer: Either return transfer of an inpatient to the primary hospital, or transfer of a patient to another hospital for recovery. Sideways transfer: Transfer of a patient to another hospital, because the required facilities at the referring hospital are fully occupied. Further Australian data will need to be collected prospectively on the costs and outcomes of patients who are transferred from one hospital to another for specific, complex treatment. In the light of these results, further analysis of transfer status will be needed, before it can be applied as a measure of illness severity and resource utilisation. Depending on these results, refinements of DRGs may then be indicated.
References
	Commonwealth Department of Health and Family Services. Report on National Aboriginal and Torres Strait Islander Casemix Study. Adelaide: Brewerton and Associates Pty Ltd, April 1997. Munoz E, Soldano R, Gross H, et al. Diagnosis related groups and the transfer of general surgical patients between hospitals. Arch Surg 1998; 123: 68-72. Jencks SF, Bobula JD. Does receiving referral and transfer patients make hospitals expensive? Med Care 1988; 26: 948-958. Pon S, Notterman DA, Kathryn M. Pediatric critical care and hospital costs under reimbursement by diagnosis-related group: effect of clinical and demographic characteristics. J Pediatr 1993; 123: 355-364. Borlase BC, Baxter JK, Kenny PR, et al. Elective intrahospital admissions versus acute interhospital transfers to a surgical intensive care unit: cost and outcome prediction. J Trauma 1991; 31: 915-918.
Authors' details
	Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC. Warwick W Butt, MD, FRACP, Staff Specialist in Intensive Care. Frank A Shann, MD, FRACP, Director of Intensive Care; and Professor of Critical Care Medicine, University of Melbourne, Melbourne. Reprints will not be available from the authors. Correspondence: Dr W Butt, Intensive Care Unit, Royal Children's Hospital, Flemington Parade, Parkville, VIC 3052. E-mail: buttwATcryptic.rch.unimelb.edu.au

	Go to the next article . . . Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1998 Medical Journal of Australia.