Challenging Hospital Activity

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Challenging Hospital Activity
East Midlands Public Health Conference May 2008

• Dr Andrew Rixom
• Consultant in Public Health Nottingham City PCT

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Acutality?

• Resource Allocation
• Trust Finance Director
• Thats what I need to run a hospital(and I
  really need more)
• PCT Finance Director
• Last year plus a bit less than you want(and
  thats more than I can afford or you need)
• Dispute and split difference
• Adjust planned activity/costs to fit.
• Resource Use
• Trust over performs back to original demand ()
• Why does it cost what it does?

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PBR

• Any agreed method of counting activity is a local
  currency to produce agreed quantum
• PBR upsets status quo because its national, uses
  averages, and changes the quantum
• Generates critically appraisal of activity and
  cost for PBR and non PBR
• Issue for WCC. PBR is activity based currency not
  an outcome one.

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Why do it?

• Accuracy and discipline for the Trust
• Cross subsidisation
• Programme budget
• Needs assessments
• Performance management (trust and own)
• Save money (?)

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What's Necessary

• Investigation
• Extremely detailed population based
• Nationally benchmarked
• Structures
• Senior level decision taking meetings
• Relationship with Trust IT
• Will
• PCT in red
• Trust in the black

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What to do?

• Systematic problems
• Allocation of patients
• Count of activity
• Administrative coding
• Implied care pathways
• Upcoding
• Excluded from PBR
• Individual Patient checks
• Allocation of patients
• Incorrect coding
• Combination

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How to do it?

• Investigative
• Scoping
• Following the data
• Routine wont work
• Identifying problems
• Once identified then check routinely
• Then stop routine
• Need skills
• Database
• Clinical
• Influence
• Part of challenge
• Time (lots) and no distractions

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Data
Process
Process
Board Extract
PAS
Board Reports
Process
SLAM Extract
BILL
Process
Other Sources
Entry
Process
CDS
Protocol
CDS Extract
Process
SUS
Training
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Data

• PAS highly customised
• Understand business rules
• What does trust think they are
• What they actually are (programmed)
• Differ even when not intended
• Differ by intention
• Differ between Trusts

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Allocation

• Check
• Internal - GP matches Practice matches PCT
• External - NSTS shows patient registered with GP
• Incorrect
• Closed questions (Is your GP still.? Yes)
• Deliberate (Visitors, un-entitled, unknown,
  continuing after moved
• Routine once local issued identified
• 120K pop PCT 1.2M for business rules
• 120K pop PCT 600K incorrect info
• 300K pop PCT 750K incorrect info
• Not an issue for trusts paid the same
• Netting off if all PCTs do it

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Activity Count

• Triangulate
• SLAM, CDS/SUS, Board, Bill, plan
• Discrepancies
• Bulk recoding of maternity to NEL (500K)
• LoS in SLAM different to CDS (1.2M)
• ITU days not removed (100K)
• Local codes changed to costly national ones

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Administrative Coding (MASSIVE)

• Transfer as new admission
• Internal (6M at a DGH)
• External (double counting for LAA targets)
• OP as daycase
• Retinal cautery 800 excess admissions large Trust
• Acupuncture 3500 excess admissions large Trust
• Maternity 2500 excess admission at DGH
• OP/AE/Daycase within IP
• Visiting consultant IP spell within other IP
  spell
• Original daycase converts to IP both remain
• Original daycase complications then IP
• Zero LoS NEL admission (Assessment)

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Implied Care Pathway

• Patient tracked through system
• Maternity
• 9 months prior to birth
• All OP, IP and AE
• Does it make sense?
• Non Elective admission Tues Fri for 4 weeks
• Coding groups/associations cf other Trusts
• Change over time
• Change of OP to IP with overall count the same

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Implied Care Pathway

• Regular Admission
• Planned sequence of admissions (day or night)
• Chemotherapy obvious (not PBR yet)
• Many others
• Maternity
• Haematology
• Pain Clinic
• Polycythemia
• IV antibiotics
• HRGs but excluded PBR
• Nationally 40 HRG cost
• 5 IP in 6 months same specialty (600K at DGH)
• Daycase with same HRG within 7 days three times
  in one month(2M large Trust)

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Exclusions

• High cost procedures/drugs
• Individual prescription audit
• HIV for 3 patient at distant Trust to PCT Why?
• RA disease modifying drugs -but 10 times dose
• Auditable systems required
• Beware dual use

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Upcoding

• National benchmarking of HRG
• Any individual HRG
• Drift between with and without complication pairs
• Drift lt70 w/o complications gt69 or with
  complications pairs
• Complex elderly increasing
• Unique events (births, deliveries)
• N03 Minor abnormalities SAR
• at large Trust is 459
• at DGH is 66
• National benchmark of activity compared with
  national benchmark of cost

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Upcoding

• Changes in time
• Step Changes
• Agreed?
• Depth of coding
• Large Trust twice as many as local DGH
• Large Trust up to 14 diagnoses and procedures
• Elderly living alone, dementia, constipation
• L47/8 Renal replacement therapy (400K)
• million billion times more significant than
  clinical trial threshold of significance
• LOS compared with trimpoint
• 5000 daycase with trimpoint of 45 days (G22
  200K)
• 2000 daycase with trimpoint of 13 days (J12
  400K)
• Calculated local trimpoint and compared with
  national

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Observation

• Changing administrative coding is easier than
  pathway redesign
• Not asking clinicians to change behaviour
• Subsequently they may change from internal
  pressures
• Coding may inappropriately suggest clinicians are
  outliers (emergency readmissions or complications)

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Another Level of Challenge
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CVD Surgical Treatment 1960s

• Encourage growth of new blood vessels
• Opened chest and pericardium
• Sprinkled asbestos dust around heart
• Metal rasp
• Clinicians and patients noted a marked
  improvement in symptoms
• But..
• Mortality rates were higher when analysed
• Only the survivors thought they felt better!

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Revascularisation 2000s

• No trials comparing with medical treatment
• Look at advised intervention from current
  guidelines and compare with actual given
• 4.5 years mean survival with revascularisation
• 2-3 weeks less if have medical treatment
• Mortality higher with surgery in low/medium risk
  patients after revascularisation
• Mortality highest in low/medium risk with most
  recently introduced drug eluting stents

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Hierarchy of Evidence

• 1a Systematic Review (homogenous RCTs)
• 1b Individual RCT (narrow confidence interval)
• 1c All or None
• 2a Systematic Review (homogenous cohort studies)
• 2b Individual Cohort study or poor RCT
• 2c Outcome research (ecological studies)
• 3a Systematic Review (homogenous Case-Control)
• 3b Individual Case-Control study
• 4 Case Series or poor Cohort/Case-Control
• 5 Expert Opinion (no critical appraisal of above)

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RCOG Guidelines 2000Early Pregnancy Assessment

• Expert opinion
• 50,000 surgical evacuations for foetal loss a
  year
• Recent RCT shows only benefit is surgery in hours
• No intervention for foetus therefore no benefit
• No real benefit to mother (some reassurance)
• Cost
• Trust A 1M inpatient service per 100,000
  pop/year
• Trust B 150K outpatient service per 100,000
  pop/year
• New guidelines recommend outpatient service

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Patient Related Outcome Measures

• Hierarchy of Evidence
• One dimension
• Assesses validity
• Patient Related
• Live Longer
• Live Better
• (appreciate health services?)
• Not disease markers, risk factors and process
  measures

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Questions?