O desenvolvimento dos "Diagnosis Related Groups"- DRGs. Metodologia de classifica����o de pacientes hospitalares

�� descrito o processo de desenvolvimento do sistema de classifica����o de pacientes internados em hospitais que atendem casos agudos, denominada Diagnosis Relatd Group - DRGs, desenvolvido e difundido por pesquisadores da Universidade de Yale, USA. Esse sistema vem a ser um instrumento que permite a mensura����o do produto hospitalar, principalmente sob o ponto de vista gerencial. S��o apresentadas considera����es acerca do que �� entendido como produto hospitalar, seguindo nos meandros do desenvolvimento dos primeiros DRGs, at�� a mais recente revis��o do sistema. �� descrita sua utiliza����o em alguns pa��ses e diversos usos potenciais desse sistema, que abrangem desde o uso para pagamento a instrumento de controle de qualidade.

Implications of diagnosis related groups (DRGs) for the management of hospitals.

Although tremendous advances have been made in the diagnosis and treatment of patients, hospital administrative systems have progressed relatively slowly. The types of information available to managers in industrial sectors are not available in the health sector. For this reason, many phenomena, such as the variations of average costs and lengths of stay between different hospitals, have remained poorly explained.The DRG system defines groups of patients that consume relatively homogeneous quantities of hospital resources. On the basis, it is possible to standardize average lengths of stay and average hospital costs in terms of the differences in case mix treated. Thus DRGs can serve as an explanation of variations in these factors between different hospitals, and also (but not only) for prospective reimbursement schems. As in a number of other European countries, a project has been set up in Switzerland to examine the possibilities of using DRGs in hospital management, planning and financing.

Pratiques comptables des h��pitaux et faisabilit�� d'un calcul de co��ts bas��s sur les Diagnosis Related Groups

Travaux effectu��s dans le cadre de l'��tude "Case Mix" men��e par l'Institut universitaire de m��decine sociale et pr��ventive de Lausanne et le Service de la sant�� publique et de la planification sanitaire du canton de Vaud, en collaboration avec les cantons de Berne, Fribourg, Gen��ve, Jura, Neuch��tel, Soleure, Tessin et Valais

Liste des Diagnosis Related Groups et hi��rarchie des interventions chirurgicales par MDC

Travaux effectu��s dans le cadre de l'��tude "Case Mix" men��e par l'Institut universitaire de m��decine sociale et pr��ventive de Lausanne et le Service de la sant�� publique et de la planification sanitaire du canton de Vaud, en collaboration avec les cantons de Berne, Fribourg, Gen��ve, Jura, Neuch��tel, Soleure, Tessin et Valais

Diagnosis Related Groups (DRGs) and the medicare program : implications for medical technology.

"OTA-TM-H-17"--P. [4] of cover.

Distribution des dur��es de s��jour par Diagnosis Related Group

Ce cahier fournit les principales informations concernant les dur��es de s��jour et le nombre de sorties observ��es dans 33 h��pitaux suisses pour l'ann��es 1984. La description des client��les hospitali��res est fond��e sur les "Diagnosis Related Groups" (DRG), qui forment une classification de 472 groupes de patients hospitalis��s. [Auteurs, p. 1]

Nucleophile-Catalyzed Additions to Activated Triple Bonds. Protection of Lactams, Imides, and Nucleosides with MocVinyl and Related Groups

Additions of lactams, imides, (S)-4-benzyl-1,3-oxazolidin-2-one, 2-pyridone, pyrimidine-2,4-diones (AZT derivatives), or inosines to the electron-deficient triple bonds of methyl propynoate, tert-butyl propynoate, 3-butyn-2-one, N-propynoylmorpholine, or N-methoxy-N-methylpropynamide in the presence of many potential catalysts were examined. DABCO and, second, DMAP appeared to be the best (highest reaction rates and E/Z ratios), while RuCl3, RuClCp*(PPh3)2, AuCl, AuCl(PPh3), CuI, and Cu2(OTf)2 were incapable of catalyzing such additions. The groups incorporated (for example, the 2-(methoxycarbonyl)ethenyl group that we name MocVinyl) serve as protecting groups for the above-mentioned heterocyclic CONH or CONHCO moieties. Deprotections were accomplished via exchange with good nucleophiles: the 1-dodecanethiolate anion turned out to be the most general and efficient reagent, but in some particular cases other nucleophiles also worked (e.g., MocVinyl-inosines can be cleaved with succinimide anion). Some structural and mechanistic details have been accounted for with the help of DFT and MP2 calculations.

Nucleophile-Catalyzed Additions to Activated Triple Bonds. Protection of Lactams, Imides, and Nucleosides with MocVinyl and Related Groups

Additions of lactams, imides, (S)-4-benzyl-1,3-oxazolidin-2-one, 2-pyridone, pyrimidine-2,4-diones (AZT derivatives), or inosines to the electron-deficient triple bonds of methyl propynoate, tert-butyl propynoate, 3-butyn-2-one, N-propynoylmorpholine, or N-methoxy-N-methylpropynamide in the presence of many potential catalysts were examined. DABCO and, second, DMAP appeared to be the best (highest reaction rates and E/Z ratios), while RuCl3, RuClCp*(PPh3)2, AuCl, AuCl(PPh3), CuI, and Cu2(OTf)2 were incapable of catalyzing such additions. The groups incorporated (for example, the 2-(methoxycarbonyl)ethenyl group that we name MocVinyl) serve as protecting groups for the above-mentioned heterocyclic CONH or CONHCO moieties. Deprotections were accomplished via exchange with good nucleophiles: the 1-dodecanethiolate anion turned out to be the most general and efficient reagent, but in some particular cases other nucleophiles also worked (e.g., MocVinyl-inosines can be cleaved with succinimide anion). Some structural and mechanistic details have been accounted for with the help of DFT and MP2 calculations.

Diagnostic Related Groups (drgs): Resourceful tools for financial crisis times?

This document is intended to be read by the Colombian Ministry of Social Protection (former MoH) and includes some recommendations that could be implemented on the aim to increase allocative efficiency, thus improving macroeconomic performance of the Colombian Health System (CHS). It will be conducted as follows: first it will briefly review the background and actual context of the CHS, after this, will mention some related issues that justify a policy intervention on strategic purchasing to promote long run sustainability and hopefully the future attainment of major goals such as universal coverage and quality improvement. After prioritizing the main financial threats to the system, based on findings from literature review from countries that have successfully implemented similar policies, this paper will make some policy recommendations on regards especially to inpatient health care services in Colombia.

Avalia����o de desempenho de servi��os de sa��de

A partir da literatura recente (at�� 1988) a respeito da avalia����o de servi��os de sa��de em geral e do desempenho hospitalar em particular, destacam-se os diferentes aspectos conceituais e metodol��gicos envolvidos, come��ando pelas primeiras tentativas no seio do Col��gio Americano de Cirurgi��es, passando pela cria����o e evolu����o da Comiss��o Conjunta de Acredita����o de Hospitais americana, at�� os esfor��os e elabora����es conceituais e metodol��gicas mais recentes. S��o destacados a metodologia dos grupos diagn��sticos homog��neos ("diagnosis related groups" ou "DRGs") e os indicadores de gravidade ("severity of illness"). �� comentada a evolu����o desse incipiente campo de conhecimento e de pr��tica no ambiente nacional. S��o comentadas as origens do recente interesse internacional a respeito do problema, ou seja, o aumento generalizado de custos dos servi��os de sa��de, crescente aumento de demandas judiciais em alguns pa��ses e ainda o acentuado incremento de complexidade dos atos em muitas especialidades. Destacam-se as fontes de informa����o correntemente utilizadas no processo, ou seja, a observa����o direta (estudos caso/controle), os prontu��rios m��dicos e os instrumentos-resumo, freq��entemente utilizados para remunera����o do atendimento. Mencionam-se as profundas influ��ncias na pr��tica de sa��de que o processo de avalia����o tem introduzido, particularmente a padroniza����o de procedimentos, o estadiamento de agravos, os estudos de trajet��ria, os relacionados a situa����es tra��adoras ("tracers") e a alternativa que mais tem influenciado a pr��tica de situa����es complexas de sa��de, que s��o os protocolos diagn��stico-terap��utico s j�� amplamente utilizados em algumas ��reas como a do tratamento de c��ncer, inclusive no Brasil.

Modelling HIV/AIDS length of stay in Portugal

Tese apresentada como requisito parcial para obten����o do grau de Doutor em Estat��stica e Gest��o de Informa����o pelo Instituto Superior de Estat��stica e Gest��o de Informa����o da Universidade Nova de Lisboa

Financiamento hospitalar em Portugal : incentivos �� selec����o e equidade

RESUMO - Contexto: O sistema de financiamento do internamento hospitalar p��blico Portugu��s �� de natureza prospectiva, atrav��s de um or��amento global baseado no casemix para os doentes do Servi��o Nacional de Sa��de (SNS) e de um pagamento por epis��dio para os doentes dos subsistemas. Em ambos os casos, o financiamento baseia-se principalmente nos Grupos de Diagn��stico Homog��neos (GDH) correspondentes a cada epis��dio, seja para atribuir um pre��o por doente sa��do no caso dos doentes dos subsistemas, seja para calcular o casemix do hospital no caso dos doentes do SNS. Atendendo �� heterogeneidade de utiliza����o de recursos intra GDH, resultante das caracter��sticas e necessidades individuais de cada doente, �� expect��vel que o hospital, tendo em vista a garantia da sustentabilidade econ��mica e financeira e/ou a obten����o de mais-valias, procure que o custo de produ����o fique aqu��m do pre��o m��dio pago, o que pode resultar na selec����o de doentes. Por outro lado, ao n��o ser tida em conta no financiamento, e na aus��ncia de selec����o, a heterogeneidade intra GDH pode resultar na injusta recompensa/penaliza����o de uns hospitais em detrimento de outros, tendo em conta as caracter��sticas e necessidades da popula����o que servem e pelas quais n��o s��o compensados. Objectivos: O presente estudo prop��s-se, por isso, avaliar o impacte que as caracter��sticas inerentes aos doentes t��m no consumo de recursos hospitalares, tendo em vista inferir se as mesmas criam incentivos �� selec����o de doentes ou s��o fonte de penaliza����es ou recompensas injustas para os hospitais. Metodologia: Foi utilizada a amostra completa dos doentes internados no ano 2007 por doen��as e perturba����es do aparelho circulat��rio (Grande Categoria de Diagn��stico 5) nos 76 hospitais p��blicos Portugueses (69.905 epis��dios). Assumiu-se como proxy dos custos a vari��vel tempo de internamento, e avaliou-se, mediante a realiza����o de uma regress��o linear multivariada, a rela����o existente entre a varia����o no tempo de internamento e as caracter��sticas sexo, idade, severidade, comorbilidades e estatuto econ��mico dos doentes, tendo-se conclu��do que todas, menos o sexo, t��m impacte significativo no tempo de internamento. Uma an��lise preliminar da distribui����o das caracter��sticas identificadas como indutoras de custos pelos hospitais em estudo, conforme o resultado financeiro alcan��ado por estes fosse positivo ou negativo, sugeriu que as mesmas podem ter impacte nos resultados financeiros alcan��ados pelos hospitais. Conclus��o: Concluiu-se que a actual metodologia de financiamento dos hospitais p��blicos portugueses possui incentivos �� selec����o de doentes, visto possibilitar a identifica����o de doentes que pelas suas caracter��sticas se tornam menos ���rent��veis��� para os hospitais, o que se pode traduzir numa perda de qualidade assistencial e de acessibilidade para os mesmos e beneficia/penaliza uns hospitais em detrimento de outros, de acordo com as caracter��sticas da popula����o que servem.

Cost-Effectiveness of Non-Vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation in Portugal

INTRODUCTION AND OBJECTIVES:Recently, three novel non-vitamin K antagonist oral anticoagulants received approval for reimbursement in Portugal for patients with non-valvular atrial fibrillation (AF). It is therefore important to evaluate the relative cost-effectiveness of these new oral anticoagulants in Portuguese AF patients. METHODS: A Markov model was used to analyze disease progression over a lifetime horizon. Relative efficacy data for stroke (ischemic and hemorrhagic), bleeding (intracranial, other major bleeding and clinically relevant non-major bleeding), myocardial infarction and treatment discontinuation were obtained by pairwise indirect comparisons between apixaban, dabigatran and rivaroxaban using warfarin as a common comparator. Data on resource use were obtained from the database of diagnosis-related groups and an expert panel. Model outputs included life years gained, quality-adjusted life years (QALYs), direct healthcare costs and incremental cost-effectiveness ratios (ICERs). RESULTS:Apixaban provided the most life years gained and QALYs. The ICERs of apixaban compared to warfarin and dabigatran were ���5529/QALY and ���9163/QALY, respectively. Apixaban was dominant over rivaroxaban (greater health gains and lower costs). The results were robust over a wide range of inputs in sensitivity analyses. Apixaban had a 70% probability of being cost-effective (at a threshold of ���20 000/QALY) compared to all the other therapeutic options. CONCLUSIONS:Apixaban is a cost-effective alternative to warfarin and dabigatran and is dominant over rivaroxaban in AF patients from the perspective of the Portuguese national healthcare system. These conclusions are based on indirect comparisons, but despite this limitation, the information is useful for healthcare decision-makers.