DRG payment for long-term ventilator patients-revisited

Abstracts From the Literature-Pulmonary Selected DRG

Payment

ited.

Douglass

for

Long-Term

PS.

Bone

Ventilator

RC,

Rosen

by David

Patients-Revis-

RL.

Chest

93~629,

1988. This article provides a follow-up to an evaluation originahy presented in Chesr of the financial impact of diagnosis related group (DRG) payment for long-term ventilator-dependent Medicare patients at Rush-Presbyterian-St. Luke’s Medical Center. Since the results of our original study were presented, the Health Care Financing Administration (HCFA) has created two new DRGs for patients who have respiratory principal diagnoses to help recognize the resource intensiveness associated with mechanical ventilator support. The original 95 patients’ payment, which was originally calculated to be $2.2 million below costs, was recalculated to be $1.9 million below costs, representing a 13 percent reduction in the loss. We conclude that although HCFA’s recent remedial action is a step in the right direction, it provides little relief from the DRG system’s financial bias against long-term ventilator-dependent patients, because the new ventilator DRGs encompass only a small segment of these patients. As an alternative approach, we recommend a single DRG for patients who, regardless of their principal diagnoses, experience chronic respiratory failure requiring a minimum of three days of continuous ventilator treatment. (Reprinted with permission.)

Initial Experience With a Central Respiratory Unit as a Cost-Saving Alternative to the Intensive

Monitoring Care Unit

for Medicare Patients Who Require Long-Term Ventilator Support. Krieger BP. Ershowsky P, Spivack D, Thorstenson

J, Sackner

MA.

Chest

93:395,

1988.

The cost of delivering health care to Medicare patients in intensive care units (ICU), especially those on long-term ventilator support, has become a major financial burden to American hospitals. We established a central station, respiratory, noninvasive monitoring unit (NIMU) on a cardiac telemetry floor where nurse to patient ratio was 1:4 to 1:6 as a cost-effective alternative to the ICU which has a ratio of 1:2. During the first five months of operation, 55 patients were admitted to this unit, of which 11 were long-term ventilator Medicare patients. Seven of these 11 patients were successfully weaned and discharged from the hospital. Overall, a minimum of $21,724 was saved over five months by shifting these long-term ventilator patients from the ICU to the NIMU while quality of medical care remained or exceeded accepted standards. We conclude that alternative health care delivery systems such as the NIMU need to be investigated as safe, cost-reducing substitutes for selected ICU patients to prevent loss of quality medical care in the financial backlash of the present Medicare prospective payment schedule. (Reprinted with permission.)

Journal

of Critical Care, Vol 3, No 4 (December),

1988:

pp 275-284

H. lngbar Prognostic Acquired

Factors and lmmunodeficiency

Life

Expectancy Syndrome

of Patients With and Pneumocystis

carinii Pneumonia. Brenner M, Ognibene FP, Lack EE, Simmons JT, Suffredini AF, Lane, HC, Fauci AS, Parrillo, JE. Shelhamer JH, Masur H. Am Rev Respir Dis 136:1199, 1987. To assess determinants of prognosis for 43 patients with the acquired immunodeliciency syndrome (AIDS) and Pneumocystis carinii pneumonia, objective clinical and histopathologic characteristics were analyzed for acute and longterm prognostic significance. Severe abnormalities on initial chest radiographs and alveolar-arterial oxygen differences (AaPO,) greater than 30 mm Hg were associated with higher mortality during the period of treatment for the acute episode (p < 0.05). Decreased long-term survival after the diagnosis of Pneumocystis pneumonia correlated with the severity of interstitial edema (a component of diffuse alveolar damage) on initial transbronchial biopsy and elevation of AaPO, at the time of diagnosis (Cox proportional hazards analysis, p < 0.05). The persistance of Pneumocystis cysts after 3 wk of therapy was associated with significantly decreased longterm survival (p < 0.05) when follow-up biopsy was performed in 27 of the patients. Patients with a diagnosis of Pneumocystis pneumonia before July 1985 had more advanced disease at the time of diagnosis and a worse prognosis than did those in whom the diagnosis was made after July 1985 (p < 0.05). This study demonstrates that important prognostic information can be derived from information obtained at initial presentation and follow-up bronchoscopic evaluation in patients with AIDS and Pneumocystis carinii pneumonia, and suggests that early detection and initiation of therapy may improve chances for survival. (Reprinted with permission.) Survival carinii

and Prognostic Factors in Severe Pneumocystis Pneumonia Requiring Mechanical Ventilation. El-

Sadr W, Simberkog 1988.

MS.

Am

Rev Respir

Dis

137:1264,

Severe Pneumocystis carinii pneumonia (PCP) necessitating mechanical ventilation has been associated with a high mortality rate in several previous studies. This has discouraged physicians from recommending, as well as patients from accepting, mechanical ventilation when respiratory failure developed. Analysis of 19 records of patients with first episode PCP who were intubated and received mechanical ventilation showed a mortality of 57.8%. A constellation of clinical and laboratory findings was found that identified those patients more likely to survive, including a shorter duration of symptoms prior to admission, better arterial oxygenation on admission, deterioration of respiratory status soon after bronchoscopy, decrease in serum lactic acid dehydrogenase and rapid improvement in arterial blood gas determinations after institution of mechanical ventilation.

275