Quality of care before and after implementation of the DRG-based prospective payment system: a summary of effects

Article Abstract:

The effects of the prospective payment system (PPS) for Medicare patients are evaluated in a series of articles in the October 17, 1990 issue of JAMA, The Journal of the American Medical Association. Under this system, hospitals receive a fixed-fee prospective payment for each patient, based on the patient's diagnostic category. Incentives are provided to minimize the length of the hospital stay and to use lower-cost services whenever possible; this has led to concern that the quality of care may have been compromised following the implementation of this payment system. Studies included in the October 17, 1990 issue of The Journal of the American Medical Association found that, after the PPS began in 1984, the incidence of sickness at admission was higher, processes of care in the hospital were better, more patients were discharged in unstable condition, and mortality rates 30 and 180 days after admission were lower or unchanged from pre-PPS levels. This article attempts to show which changes actually can be attributed to the PPS. Fourteen variables (such as age, race, initial do-not-resuscitate orders) associated with the changes in mortality noted, were identified; the expected consequences for mortality if the variable changed were analyzed. Results showed that mortality after hospitalization was not affected by the PPS, and in-hospital processes of care have improved; however, more patients in later years were discharged home in an unstable condition. Since this result was obtained for all diagnostic groups and in all hospital types, the PPS is implicated. Arguments can be made, however, to the effect that some of the change in mortality noted for patients discharged with instability is not due to the PPS. Limitations of the study are discussed. Suggestions based on the results of the study are: patients should be more systematically assessed prior to discharge; clinical trials should be carried out to determine the effects of longer hospital stays on selected groups of unstable patients; and data regarding sickness at admission, processes of care, and other variables studied, should be continuously collected to allow ongoing evaluation of the effects of the PPS. (Consumer Summary produced by Reliance Medical Information, Inc.)

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Changes in quality of care for five diseases measured by implicit review, 1981 to 1986

Article Abstract:

The effects of the prospective payment system (PPS) for Medicare patients are evaluated in a series of articles in the October 17, 1990 issue of JAMA, The Journal of the American Medical Association. Under this system, hospitals are paid a fixed rate for each patient, according to rates determined for 470 diagnoses. The quality of care patients receive can be evaluated by either explicit or implicit review. Explicit review is based on fixed criteria established before the review process, while implicit review depends on the physician's opinions regarding the case under discussion. The current study aimed to evaluate the methods of implicit review and to use these methods to gauge changes in the quality of care for 14,012 Medicare patients before and after the establishment of PPS. Patients had been admitted with one of five diagnoses: congestive heart failure, heart attack, pneumonia, cerebrovascular accident (stroke), or hip fracture. A review of 1,366 medical records from a random sample of that group was carried out by 25 physician-reviewers, who scrutinized the patients' medical records (except nursing notes) and answered 27 questions concerning the process of physician and nursing care. Overall, the quality of care was judged to be good, with 82 percent of patients having received good or very good care, and 18 percent, poor or very poor care. Care improved in the post-PPS era (1985-1986), for all five diseases, with significant improvements for heart attack, stroke, and congestive heart failure. More patients with congestive heart failure and hip fracture were discharged in unstable condition, however, in the later period. In addition, a significant proportion of patients received poor or very poor care, indicating that there is room for improvement. Results from implicit and explicit reviews of the patients' charts were similar. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Analysis, Medical records

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Similar abstracts:

• Abstracts: Comparing outcomes of care before and after implementation of the DRG-based prospective payment system. The effects of the DRG-based prospective payment system on quality of care for hospitalized Medicare patients: an introduction to the series
• Abstracts: Prospective payment system and impairment at discharge: the 'quicker-and-sicker' story revisited. Changes in sickness at admission following the introduction of the prospective payment system

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