Printer Friendly

Cholecystectomy and diagnosis-related groups (DRGS): patient classification and hospital reimbursement in 11 European countries.


Gallbladder surgery is one of the most frequent major surgeries in general surgery departments (1) and a cholecystectomy procedure is considered a benchmark procedure for a surgeon and surgical department (due to high prevalence, relevant impact on the population's health, high clinical variability, and substantial use of resources) (2,3). Diagnosis-Related Groups (DRGs) are Patient Classification Systems (PCSs), which are commonly used to classify, benchmark and ultimately pay for hospital treatment (4). In current DRG-type hospital payment systems, DRGs define the payment categories, i.e. hospital products (4). As such, they are designed to increase the transparency about the services and provide incentives for the efficient use of resources within hospitals (4). Another type of standardized agreement in healthcare are clinical guidelines, which are also used for guiding decisions and criteria regarding diagnosis, management and treatment, and are increasingly used as benchmarks for high quality care. It is important that management tools, which provide administrative incentives for clinical decision-making, are coherent. All the above also applies to Episodes of Care (EoC) (1), such as cholecystectomy. Classifications in healthcare are needed to transform information about human health and medical interventions to facilitate aggregation, analysis, decision-making and learning among people, and increasingly between software agents (5).

A well-designed classification system that is serving as the basis for a fair hospital payment or as the basis of performance comparisons should assure homogenous groups of patients based on most important determinants of resource consumption as classification variables and do so in a systematic manner (6). Otherwise, DRGs do not adequately control for differences of patients within different groups and reimbursement or benchmarking for some patient groups will not be adequate (4). It is also possible that if the PCS that is used for payment and benchmarking purposes is performing inadequately, it creates a potential conflict of incentives for clinical professionals and managers (7,8).

DRG systems usually group treatment cases on the basis of classification variables such as diagnoses, procedures and demographic characteristics. However, DRG systems in different countries and sometimes even within countries vary a lot, and they are in a constant state of evolving (4).

Very often professional specialist experts or consultants formally participate in the process of selection, definition, and update of classification criteria for respective DRGs (9). Thus, it is of utmost importance both for specialist groups such as surgeons as well as hospital managers to be aware of how their respective patients are classified by their DRG system in order to assess whether the classification variables adequately reflect differences in the complexity of treating different groups of patients using different techniques. Comparison of different countries' DRG systems classification principles can help surgeons to identify potential scope for improvement of their system or find cross-country agreement in classification principles in the same manner and direction as clinical guidelines. Also, analysing the different approaches to assigning a value and reimbursement tag for similar patients in other DRG systems may inform and support discussions about the adequacy of the existing practice. To the best of our knowledge, detailed comparative analyses of classification algorithms for cholecystectomy are very scarce, suffer from a very limited scope, and have not assessed the classification of patients using routine inpatient data (10).

Overall, studies across Europe suggest DRG-based payment systems have been associated with reduction in unit costs but also with an increase in total cost, due in part, to increased activity (4). Whether this has improved system efficiency depends on a number of factors, including: the impact on quality; the 'value' of the additional activity in terms of health gain; and whether there was cost-shifting (for example, with greater costs being borne in community and primary care from earlier discharge for patients) and gaming of the system (through up-coding and patient selection). Very few studies have examined the impact of payments based on DRGs on system-wide efficiency (11).

For hospital care, case-mix adjusted bundled payments are well established across Europe and are being expanded to cover more types of inpatient care. While having had an impact in Europe, with respect to increasing activity and reducing Length of Stay (LOS), DRG-type payments may not alone help to improve the quality of care (particularly the coordination of care for patients beyond hospital settings), or control overall costs of hospital care (11).

This study therefore performs a comprehensive assessment of DRG systems across eleven European countries and has three main objectives: 1) to assess classification variables and algorithms used to group patients with cholecystectomy into DRGs; 2) to compare the composition of these DRGs and variations in relative resource intensity; and 3) to determine DRGs and hospital price levels for six case vignettes of cholecystectomy patients with different combinations of demographic, diagnostic and treatment variables.

The results were generated in the framework of the EuroDRG project (4), which selected ten episodes of care to assess European DRG systems and their ability to define homogenous groups of patients. In this article, we focus on cholecystectomy as it is one of the most common emergency surgical procedures in high-income countries (12-14).


Definition of episode of care and cholecystectomy index case

A common definition for a cholecystectomy EoC was agreed as part of the EuroDRG project by researchers from eleven European countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, the Netherlands, Poland, Spain, and Sweden). The definition was based on the International Classification of Diseases 10th edition (ICD-10) for diagnoses and ICD-9 Clinical Modification (ICD-9CM) for procedures and is presented in Box 1. Researchers from each country translated the definition into national codes for diagnoses and procedures considering available mappings from the Hospital Data Project if applicable (15). Similar methods have been reported for another episode of care (16-21).

A cholecystectomy index case was defined (i.e. adult age, uncomplicated calculus of gallbladder with cholecystitis, laparoscopic cholecystectomy, treated as inpatient) to facilitate comparisons of relative resource intensity of respective DRGs within countries (see Box 1).

Box 1. Definition of EoC and reference case


Name         [right arrow]   Cholecystectomy

Defined by   [right arrow]   Primary procedures
                             AND diagnosis

Primary      [right arrow]   K80.1 (Calculus
diagnosis                    of gallbladder
(ICD-10)                     with other

Procedure    [right arrow]   51.2
(ICD-9CM)                    (Cholecystectomy)

Index case

Adult age (< 36), without complications, non-specific cholecystitis,
laparoscopic cholecystectomy, treated as inpatient, LOS 4 days

Data sources

In each country, researchers identified national or regional databases of hospital care and obtained access to all information necessary for the purposes of this study. The number of cholecystectomy cases conforming to our definition and the corresponding DRGs were extracted from the databases. An overview of the databases and time interval (years) of data used for the study in each country are presented in Table 1. Databases were required to contain information about diagnoses, procedures, and DRGs of individual patients in order to make possible identification of cholecystectomy patients conform to the agreed definition. The number of identified cholecystectomy cases ranged from 1,845 cases in Finland to 73,545 cases in Poland (22).

Analysis of Patient Classification Systems (PCSs)

For each country the number of cholecystectomy EoC cases and the corresponding DRGs were extracted from the databases. Detailed comparative analyses of classification variables and of grouping algorithms of national DRG systems (16,23) were performed for the most frequent DRGs, i.e. those DRGs that individually contained at least 1% of all cholecystectomy patients in the relevant database.

Grouping algorithms were mapped graphically to facilitate easy comparison of differences and similarities between systems (see below). In addition, the percentage of all cholecystectomy EoC cases grouped into the DRG and the percentage of all cases within each DRG conforming to the definition of cholecystectomy was calculated.

Diagnosis-Related Groups (DRGs) and hospital quasi prices

In addition to the index case (see above), six standardised case vignettes of patients with different combinations of primary and secondary diagnoses, procedures, age and length of stay were defined (Table 2). This selection is meant to describe the grouping logic of different DRG systems in different countries' systems. Case vignettes one, two and three represent more complicated cases of cholelithiasis, while the remaining ones are combinations of mixed gravity of primary and secondary diagnosis and patient characteristics.

DRG-type hospital payments systems differ between and often even within countries, thus, complicating comparisons across countries. In order to compare relative resource intensity for cholecystectomy as expressed by DRGs in each country, an approach similar to that of Koechlin et al. was used (10).

Quasi prices were calculated by converting national DRG weights into monetary values using average national conversion rates. If necessary, prices were deflated to 2008 prices using national GDP deflators (24) and converted to Euros using average currency exchange rates for the year 2008 (25). In addition, a quasi-price index was calculated with the index case assuming a value of one. The index score of all other case vignettes was calculated by dividing the monetary value of the quasi price (10) of each case vignette by that of the index case.


Figure 1 shows the grouping algorithms and classification variables of PCS in the eleven European countries. The figure includes classification variables of those DRGs that individually represent at least 1% of cholecystectomy cases in each country. DRGs containing less than 1% of cases in the national database but which are essential for understanding the grouping logic are shaded in light grey and are not considered in the following analysis. The index DRGs are highlighted in dark grey. On the left hand side, the figure specifies for each country the version of the DRG system and the percentage of all identified cholecystectomy cases that are shown in the graph. The last two columns on the right show the percentage of cholecystectomy cases covered by each DRG and the DRG weight index.

On the left hand side, the figure specifies for each country the version of the PCS and the percentage of all cholecystectomy cases shown in the graph. The arrows indicate the sequence in which different types of classification variables are considered in the grouping algorithm. In addition, indicators to assess the composition of DRGs and the relative resource intensity of cases within each DRG are shown. The Finnish and the Swedish algorithms are combined as both use versions of the NordDRG system which is very similar for cholecystectomy. Grouping algorithms classify cholecystectomy cases on the basis of different classification variables: 1) type of diagnosis, 2) type of procedure, 3) type of admission, 4) the level of Comorbidities or Complications (CC), 5) age, and 6) length of stay.

Patient classification of cholecystectomy cases in Europe

The figure shows large differences in the DRG systems for the 11 European countries. For example, in Austria and Poland there are two DRGs for a cholecystectomy episode, but in England there are nine DRGs. The DRG systems in England, France and Estonia use the highest number of variables, including a variety of medical conditions and procedures. The latter is not directly included in the Frenched system, but there is a distinction between patients with acute and non-acute conditions.

The type and combination of classification variables also vary significantly across countries. The main diagnosis is used as a classification variable only in Finland, Sweden, the Netherlands and Poland. The Austrian, German and Dutch DRG systems do not differentiate patients with CC, while all other countries consider CCs in their classification system. Yet, most countries only make a distinction between patients with and without CCs, while the French GHM (homogeneous patient groups) system (26) differentiates between four levels of CCs and the German Diagnosis-Related Groups (G-DRG system) calculates cumulative Patient Clinical Complexity Levels (PCCLs) (27,28).

In all countries, the DRGs are based on cholecystectomy procedures (including both open and laparoscopic procedures). Open and laparoscopic cholecystectomy procedures are included in DRG systems in Estonia, Finland, Germany, Ireland, the Netherlands and Sweden.

Admission is accounted for in Finland, Sweden and in the Netherlands. Age serves as a classification variable only in France. Length of stay is relevant for grouping cases into DRGs only in France, although it is considered either for outlier deductions or for additional payments in a number of other countries, such as in Austria, England, Germany and France (4).

Distribution of cholecystectomy cases and variation in relative resource intensity

In most countries, the vast majority of cholecystectomy EoC cases are grouped into the shadowed DRG (in Figure 1) containing the index case (see Box 1), i.e. between 55% in Finland and 92% in Austria. Within these index DRGs, almost all patients conform to our EoC definition (i.e. around 90% or above).

The cost index shows that the index DRG is the lowest valued DRG only in Poland, England, Estonia and Spain (see Figure 2). Generally, in DRG systems with only three or four DRGs for cholecystectomy patients, even the highest valued DRG has the cost the index below two. The low variation cost index values compared to index case could be an indication of differences in coding practices across countries or poor quality data.

The lowest variation in DRG weight index scores exists in Austria, Germany, Poland and Netherlands with a range of about one. In these countries, but also in England, Finland, Sweden and France, indicating that the systems do not systematically account for cases that are more than twice as resource intensive as the index case. In contrast, the range of DRG weight index scores is considerably higher in Ireland (0.4-4.0) (see Figure 2).

Diagnosis-Related Groups (DRGs) and hospital quasi prices for case vignettes

Table 3 shows a comparison of DRGs and hospital quasi prices, reflecting national average hospital payments for each case vignette under the assumption that hospital payment would be exclusively based on DRGs. For each case vignette, the first column specifies the DRG into which a patient would be classified and whether he or she would be considered an inlier or an outlier, i.e. whether the predefined length of stay is above or below the DRG system specific upper or lower length of stay threshold. The second column specifies the corresponding quasi price for each patient. In the last column of the table, the index DRGs (see Figure 1) and corresponding quasi prices are presented.

Apparently, large variation in hospital payments exists across countries. Index case forms the majority of total cases. Index case is generally a patient with milder condition, without comorbidities. However it is observed that only for Estonia, England, Poland and Spain the payment for index case is lower than for other patient groups. Cases with lower payments are mostly found in patient group 5 (day-care laparoscopic without CC). Cases in patient group 5 are considerably cheaper compared to the index case in Finland, France, Germany, Ireland, the Netherlands and Sweden. Similar payment compared to the index case is found in Austria, England, Estonia, Poland and Spain but this is due to the fact that patient group 5 includes the same DRGs as in the index case.

DRG price is lower compared to the index case in patient group 4 (day-care laparoscopic with CC). The DRG cost of this group is lower in almost every country except for England, Estonia and Spain. In Finland the DRG price is comparable with index case.

The most pricey DRG is in patient group 1 (open with CC), which is to be expected because patients in this group have undergone open cholecystectomy, with CC and a long LOS. Expensive DRGs are also found in patient groups 2 (laparoscopic with CC) and 3 (laparoscopic without CC), although in patient group 3 the DRG cost is similar to the index case in Germany and the Netherlands.

The lowest DRG payment level is in Poland but the most expensive in Ireland. For example, the cost of the index case is 742 euros in Poland, compared to Ireland where it is 4,645 euros. Moreover, in patient group 1 this difference is considerably higher (837 euros versus 18,475 euros).

Figure 2 shows the ratio of the quasi price of each DRG compared to a cholecystectomy without complications (index case) per country. The largest variations are found in England, Ireland, Spain and Estonia, where patients with open cholecystectomy (vignette 1) have a quasi price that is more than twice as high as that of the index case. In contrast, only slight variations exist in Austria, Poland and the Netherlands. In half of the countries, payment for a day case without complications (vignette 4 and 5) is below that of the index case. Other countries do not have specific DRGs for day cases but apply a LOS-based payment reduction for cases staying shorter than a lower LOS threshold, and this also applies for day cases.


This is the most comprehensive available comparative analysis of grouping algorithms, classification variables, and prices for cholecystectomy patients in different DRG-based hospital payment systems in Europe. It shows great variation across countries: 1) in the number of DRGs; 2) in the characteristics of classification variables; 3) in the degree of differentiation between complex and less complex cases; and 4) in the quasi prices for different types of patients (case vignettes).

If DRG systems do not adequately account for differences among patients, hospitals and surgeons that treat a greater share of more complex cases are not adequately compensated for their greater efforts. Possibly, in countries with only a few DRGs in order to account for differences in complexity, some of the variations in patient populations among hospitals are accounted for through adjustments (e.g. for teaching status or type of hospital) outside of the DRG systems (9). However, ideally, differences in patient characteristics would be accounted for in the PCS and not in the payment system. The implementation of DRGs also raises several other issues. In particular, the same clinical situation should be approached in an uniform way, but different systems of incentive-based funding may induce a potential conflict of interest for a doctor. In the worst case, the financial incentives could lead to treatments that are clinically inappropriate and to differences in DRG coding motivated by those incentives (29).

Moreover, it does not come out from the study what are the reasons behind the fact that the same clinical situations are priced differently in comparison to the index case. Also, the question arises as to what extent the other factors are reflected in the DRG cost. In most countries the co-morbidities and complications are taken into account in DRGs but their influence on DRG cost is most probably not uniform. Thus, the question arises as to how much the co-morbidities affect the actual prices.

The DRG system may be observed in several aspects. First, their logic is not always the same, even though there is consensus about treatment. Technically, DRGs need to be based on both economically and clinically meaningful groups. That requires careful decisions on the design of the DRG system, such as the hierarchy and algorithms used to classify patients into a limited number of groups. Economically, patients within one group should have homogeneous costs. Clinically, cases allocated to one group should form a distinguishable entity based on main diagnosis, severity, co-morbidity and/or treatment performed. But what exactly is homogeneous? When are costs and/or clinical diagnosis so different that a group should be split? (30). Second, DRGs are put together electronically on the basis of input data. Since an electronic format is used, there is a risk that a lack of data may cause conflicts (administrative side, money, information, treatment algorithms, etc.). Thus, the question arises whether the DRG system still takes into account all the needs. Administrators of a DRG system adjust rules for split, fusion or other changes in DRGs. DRGs should be put together according to common guidelines, to ensure its safety, transparency and, immunity against manipulations.

In drawing meaningful conclusions from this study, it is important to be cognisant of its limitations, especially in relation to the ability to undertake direct cross-country comparisons. First, although there was an agreed definition for cholecystectomy, relevant cases in each country were identified using a different procedure and (to a lesser extent) diagnosis coding schemes. In the absence of a common procedure classification system [such as the World Health Organization (WHO) has developed for diagnoses], there is a considerable cross-country divergence in the schemes implemented. Second, coding practice differs across countries. There is variation in coding depth: the maximum number of diagnoses used in DRG assignment is ten in Finland, but 120 in Germany. Furthermore, the propensity to record diagnoses and procedures may be related to whether the DRG system is used in hospital reimbursement.


Our study has several limitations. Firstly, the data used to identify patients and to assess the relative importance of different DRGs in different countries, originated from routine inpatient databases in eleven countries (see Table 1). Although the data can be compared, it must be taken into account the fact that countries have different coding practices and the quality may not be entirely comparable.

Secondly, countries have different payment systems for hospitals, and consequently make the payment levels difficult to compare (see Table 3). On the one hand, countries set DRG-based payment rates at varying levels as they include different cost categories. For example, in Germany, fixed capital costs are not included in DRG-based payment, whereas in most other countries, DRG-based payments are supposed to cover capital costs (10). Different systems of additional payments exist, e.g. England assigns additional Health Resource Groups (HRGs) for certain diagnostic evaluations, such as CT scans; Poland and Austria have additional per-diem based payments for stays in intensive care units (23). Furthermore, in the Dutch and the Finnish DRG systems several DRGs per hospital stay can be assigned, each leading to additional DRG-based payments (4). DRG-based payments are adjusted in several countries to account for differences among hospitals or regions. Therefore, the absolute price levels should not be directly interpreted as reflecting more expensive care in one country compared to another. However, relative price levels within countries that were used for comparisons in Figure 2 should be less affected by differences in payment systems as they were always compared to the in-country DRG index case. Thirdly, as we limit part of our comparative analysis to DRGs that account for at least 1% of cases (Figure 1), we partially neglect how different systems deal with rare outliers, which may, however, be particularly relevant for reimbursement (31). In addition, there is one more limitation in this study; it is possible that some patients were inappropriately coded in order to maximize revenues ("up-coding").

Despite these limitations, our study has major implications for surgeons, hospital managers and national authorities involved in the redesigning of national DRG systems. First, awareness about classification algorithms and variables in other countries should encourage surgeons to think about alternative and possibly better ways to classify their patients into DRGs. For example, three countries (Austria, the Netherlands and Germany) do not distinguish between cholecystectomy cases with complications. The average length of stay is taken into account only in the French DRG system, although it greatly affects the price of a cholecystectomy episode. The price index of patient groups 4 (day-care laparoscopic with CC) and 5 (day-care laparoscopic without CC) is lower (<1) for patients in France, Germany, Ireland, Netherlands and Sweden (see Figure 2). Seven countries (except Austria, England, Poland and France) differentiate between open and laparoscopic cholecystectomy, which is a very important measure for differentiating patients with an episode of cholecystectomy. Second, DRG systems are meant to provide precise measures of the kind of services hospitals deliver. This measure is useful only if DRGs describe a sufficiently homogenous group of patients (30). Therefore, quantitative research is needed to verify whether the most important determinants of cost are considered in different PCSs, and whether differences among systems reflect country specific differences in treatment patterns. However, it is also important for clinicians to be aware of the significance of adequately designed DRG systems and to engage in optimizing these systems. Information presented in this article about how DRG systems classify cholecystectomy patients can help surgeons engage with national DRG authorities. In the light of increasing pressure for cost containment, it is very important that DRG systems consider the most important classification variables in order to ensure that limited resources are appropriately allocated for patients undergoing cholecystectomy.


The present survey shows that the DRG systems can be compared, even though there are many limiting factors, arising from the particular national characteristics. These international comparisons can provide a very useful new perspective especially when governments, Ministries of Health or payers are investigating how to improve an existing DRG system. These researches can also allow countries, which are introducing DRG system, to avoid making gross errors or mistakes in composing their DRG system.

Key Messages

Implications for policy makers

* The result of this study can help policy-makers to consider alternative and possibly better ways to classify their patients into Diagnosis-Related Groups (DRG).

* DRG systems are meant to provide precise measures of the kind of services hospitals deliver.

* The international comparisons can provide a very useful new perspective especially when governments, Ministries of Health or payers are thinking about how to improve an existing DRG system.

* These researches can also allow countries, which are introducing DRG system, to avoid making gross errors or mistakes in composing their own DRG system.

Implications for public

Surgeons and national Diagnosis-Related Group (DRG) authorities should consider how other countries' DRG systems classify cholecystectomy patients in order to optimize their DRG systems and to ensure fair and appropriate reimbursement.

doi: 10.15171/ijhpm.2014.121

Article History:

Received: 20 May 2014

Accepted: 8 November 2014

ePublished: 13 November 2014


The results presented in this paper were generated as part of the project 'Diagnosis-Related Groups in Europe: Towards Efficiency and Quality (EuroDRG), which was funded by the European Commission within the Seventh Framework Research Programme (Grant Agreement Number FP7223300). We are grateful to all our project partners who made this work possible. We also acknowledge helpful comments received from the journal editors, to the anonymous referees and Wilm Quentin.

Ethical issues

The project was funded through the Seventh Framework Programme (FP7) of the European Commission under Grant Agreement Number 223300.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

EuroDRG group provided the general framework for research design; GPA, AA and MS contributed to literature searches, analysis of the results and their interpretation; GPA drafted the initial manuscript. GPA was the main contributor; other co-authors contributed to specific minor parts and by responding to reviewers' remarks and recommendations. All authors read and approved the final manuscript.


(1.) Liu B, Beral V, Balkwill A, Green J, Sweetland S, Reeves G, et al. Gallbladder disease and use of transdermal versus oral hormone replacement therapy in postmenopausal women: prospective cohort study. BMJ 2008; 337: a386-a. doi: 10.1136/bmj.a386

(2.) Khan M, Nordon I, Ghauri A, Ranaboldo C, Carty N. Urgent cholecystectomy for acute cholecystitis in a district general hospital--is it feasible? Ann R Coll Surg Engl 2009; 91: 30-4. doi: 10.1308/003588409X359024

(3.) Lee JA. Taking cover. Lancet Oncol 2004; 5: 516. doi: 10.1016/S1470-2045(04)01533-5

(4.) Busse R, Geissler A, Quentin W, Wiley M. Diagnosis-Related Groups in Europe. Buckingham: Open University Press; 2011.

(5.) Tang P, Hammond E. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Washington, DC: Institute of Medicine; 1997.

(6.) Kimberly J. The Globalization of Managerial Innovation in Health Care. Cambridge: Cambridge University Press; 2008.

(7.) Hovenga EJ, Kidd MR, Garde S, Cassio C. Health Informatics: An Overview. Amsterdam: IOS Press; 2010.

(8.) Planells Roig M, Cervera Delgado M, Bueno Lledo J, Sanahuja Santaf A, Garcia Espinosa R, Carbo Lopez J. [Surgical Complexity Classification Index (SCCI): a new patient classification system for clinical management of laparoscopic cholecystectomy]. Cir Esp 2008; 84: 37-43. [In Spanish]

(9.) National Health Service (NHS). The Casemix Service. Leeds, England: The Information Centre for health and social care; 2010.

(10.) Koechlin F, Lorenzoni L, Schreyer P. Comparing Price Levels of Hospital Services Across Countries: Results of Pilot Study. OECD Health Working Papers No. 53. Paris: OECD; 2010.

(11.) Charlesworth A, Davies A, Dixon J. Reforming payment for healthcare in Europe. Research report: KPMG cutting throught complexity; 2012.

(12.) Halilovic H, Hasukic S, Matovic E, Imamovic G. Rate of complications and conversions after laparoscopic and open cholecystectomy. Medicinski Arhiv 2011; 65: 336-8.

(13.) Dumonceau JM, Tringali A, Blero D, Deviere J, Laugiers R, Heresbach D, et al. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2012; 44: 277-98. doi:10.1055/s-0031-1291633

(14.) Ivatury SJ, Louden CL, Schwesinger WH. Contributing factors to postoperative length of stay in laparoscopic cholecystectomy. JSLS 2011; 15: 174-8. doi: 10.4293/108680811X13022985132254

(15.) HDP2. Hospital data project phase 2: final report. The equal need for metadata and data. The Netherlands: Prismant; 2008.

(16.) Quentin W, Scheller-Kreinsen D, Geissler A, Busse R. Appendectomy and diagnosis-related groups (DRGs): patient classification and hospital reimbursement in 11 European countries. Langenbecks Arch Surg 2012; 397: 317-26. doi:10.1007/s00423-011-0877-5

(17.) Scheller-Kreinsen D, Quentin W, Geissler A, Busse R, Group E. Breast cancer surgery and diagnosis-related groups (DRGs): patient classification and hospital reimbursement in 11 European countries. Breast 2013; 22: 723-32. doi: 10.1016/j.breast.2012.11.001

(18.) Quentin W, Ratto H, Peltola M, Busse R, Hakkinen U. Acute myocardial infarction and diagnosis-related groups: patient classification and hospital reimbursement in 11 European countries. Eur Heart J 2013: ehs482. doi: 10.1093/eurheartj/ehs482

(19.) Bellanger MM, Quentin W, Tan SS. Childbirth and Diagnosis Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries. Eur J Obstet Gynecol Reprod Biol 2013; 168: 12-9. doi: 10.1016/j.ejogrb.2012.12.027

(20.) Tan SS, Chiarello P, Quentin W. Knee replacement and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries. Knee Surg Sports Traumatol Arthrosc 2013; 21: 2548-56. doi: 10.1007/s00167-013-2374-6

(21.) Gaughan J, Kobel C. Coronary artery bypass grafts and diagnosis related groups: patient classification and hospital reimbursement in 10 European countries. Health Econ Rev 2014; 4: 4. doi: 10.1186/s13561-014-0004-8

(22.) Paat-Ahi G, Swiderek M, Sakowski P, Saluse J, Aaviksoo A, EuroDRG group. DRGs in Europe: A cross country analysis for cholecystectomy. Health Econ 2012; 21: 66-76. doi: 10.1002/hec.2833

(23.) National Health Service (NHS). HRG4 2009/10 Reference Costs Grouper. National Health Service; 2009.

(24.) Organisation for Economic Co-operation and Development (OECD). Health expenditure and financing [internet]. 2010 [cited 2010]. Available from:

(25.) European Central Bank (ECB). ECB. Bilateral--Exchange rates--ECB Statistical Data Warehouse. ECB; 2011.

(26.) Chevreul K, Durand-Zaleski I, Bahrami SB, Hernandez-Quevedo C, Mladovsky P. France: Health system review. Health Syst Transit 2010; 12: 1-291.

(27.) Hensen P, Beissert S, Bruckner-Tuderman L, Luger TA, Roeder N, Muller ML. Introduction of diagnosis-related groups in Germany: evaluation of impact on in-patient care in a dermatological setting. Eur J Public Health 2008; 18: 85-91. doi:10.1093/eurpub/ckm059

(28.) Ockenga J, Freudenreich M, Zakonsky R, Norman K, Pirlich M, Lochs H. Nutritional assessment and management in hospitalised patients: Implication for DRG-based reimbursement and health care quality. Clin Nutr 2005; 24: 913-9. doi: 10.1016/j.clnu.2005.05.019

(29.) Marker-Hermann E, Folsch UR, Weber M. DRG-funding of hospitals and bonus systems for physicians: Stop abberrations provoked by false incentives! Current Concerns 2012; 42: 10.

(30.) Busse R, Schreyogg J, Smith PC. Hospital case payment systems in Europe. Health Care Manag Sci 2006; 9: 211-3.

(31.) Hornung H, Jauch K, Strauss T. Betriebswirtschaftliche Bedeutung von Komplikationen in der Viszeral- und Thoraxchirurgie im DRG-System (Economic Consequences of Complications in Abdominal and Thoracic Surgery in the German DRG Payment System). Zentralbl Chir 2010; 135: 143-88.

Gerli Paat-Ahi [1,2] *, Ain Aaviksoo [1,3], Maria Swiderek [4,5]--on behalf of the EuroDRG group

Authors' affiliations

[1] PRAXIS Centre for Policy Studies, Tallinn, Estonia. [2] Department of Public Health, University of Tartu, Tartu, Estonia. [3] Technomedicum of TUT, Tallinn University of Technology, Tallinn, Estonia. [4] Department of City and Regional Management, Faculty of Management, University of Lodz, Lodz, Poland. [5] National Health Fund, Poland.

* Correspondence to:

Gerli Paat-Ahi


(1.) The EoCs are uniformly defined across countries through diagnosis and/or procedure codes and can be understood as 'meta-DRGs' which encompass varying numbers of actual DRGs within countries.

Table 1. Data years and databases by country

Country       Data     Source of data    Diagnoses   Procedure
              year                       coding      coding

Austria       2008     Procedure-        ICD-10-     Leistungs-
                       oriented          BMSG-2001   katalog
                       Financing (LKF)
                       Ministry of
                       Health (BMG)

England       2007-8   Hospital          ICD-10      Office of
                       Episode                       Population
                       Statistic (HES)               Censuses and
                                                     Surveys (OPCS)

Estonia       2008     Estonian Health   ICD-10      NOMESCO
                       Insurance Fund                Classification
                       (EHIF) database               of Surgical

Finland       2008     Hospital          ICD-10-FI   NCSP-FI

France        2008     Programme of      CIM-10      Classification
                       Medicalization                Commune des
                       of Information                Actes Medicaux
                       Systems:                      (CCAM)
                       surgery and
                       (PMSI MCO)

Germany       2008     Diagnosis         ICD-10-GM   OPS
                       Related Groups                Operationen-
                       (DRG-                         und
                       statistik) of                 Prozedurens-
                       the Federal                   chlussel

Ireland       2008     Hospital          ICD-10-AM   Australian
                       Inpatient                     Classification
                       Enquiry (HIPE)                of Health
                       database of the               Interventions
                       Health Services               (ACHI)
                       Executive (HSE)

Netherlands   2008     Diagnose          ICD-10      Elektronische
                       Behandeling                   DBC
                       Combinaties                   Typeringslijst
                       (DBC) Onderhoud

Poland        2009     Register of       ICD-10      ICD-9-CM
                       episodes of
                       care and
                       of the National
                       Health Fund

Sweden        2008     The National      ICD-10-SE   KVA
                       Patient                       Klassifikation
                       Register (NPR)                av vardatgarder
                       of The Board of               (Swedish
                       Health and                    adaption of
                       Welfare                       NCSP)

Spain         2008     Hospital          ICD-9-CM    ICD-9-CM
(Catalonia)            Minimum Basic
                       Data Set (CMBD)
                       database of the
                       Public Hospital
                       Network of

Table 2. Case vignettes: Patient classification variables

                                 Primary      Secondary
                                diagnosis     diagnoses

Index case                        K80.1          No
Patient 1 Open with CC            K80.0     E11.8, I50.1,

Patient 2 Lap with CC             K80.1         T81.4
Patient 3 Lap without CC          K80.4          No
Patient 4 Day lap with CC         K80.2     E11.9, I11.9
Patient 5 Day lap without CC      K80.2          No
Patient 6 Open without CC         K80.0          No

                                Cholecystectomy   Age     Setting

Index case                       Laparoscopic     <36    Inpatient
Patient 1 Open with CC               Open          85    Inpatient

Patient 2 Lap with CC            Laparoscopic      49    Inpatient
Patient 3 Lap without CC         Laparoscopic      55    Inpatient
Patient 4 Day lap with CC        Laparoscopic      69    Day case
Patient 5 Day lap without CC     Laparoscopic      25    Day case
Patient 6 Open without CC            Open          42    Inpatient

                                Death during    LOS
                                 admission     (days)

Index case                           No          4
Patient 1 Open with CC              Yes          9

Patient 2 Lap with CC                No          16
Patient 3 Lap without CC             No          4
Patient 4 Day lap with CC            No          1
Patient 5 Day lap without CC         No          0
Patient 6 Open without CC            No          6

LOS= Length of Stay; CC= Comorbidities or Complications

A list of relevant ICD-10 codes is provided as online material

Table 3. Comparison of hospital quasi prices for cholecystectomy
patients in Europe (in 2008 prices)

                         Index case

              DRG                  Quasi price
              (In-/outliner)       (Euros)

Austria (1)   Mel05.05B (Inlier)   3,541
England (2)   GA10B (Inlier)       1,785
Estonia (3)   494 (Inlier)         746
Finland (4)   494                  3,739
France (5)    07C141 (Inlier)      3,13
Germany (6)   H08B                 2,512
Ireland       H08B (Inlier)        4,645
Netherlands   110003230303         3,483
Poland (7)    G25 (Inlier)         742
Spain         494                  3,057
Sweden        494 (Inlier)         3,876

                         Patient 1

              DRG                   Quasi price
              (In-/outliner)        (Euros)

Austria (1)   Mel05.05B (Outlier)   4,443
England (2)   FZ12A (Inlier)        4,594
Estonia (3)   197 (Inlier)          2,34
Finland (4)   197                   5,781
France (5)    07C133 (Inlier)       7,116
Germany (6)   H07B                  4,603
Ireland       H07A (Inlier)         18,475
Netherlands   110003230203          5,790
Poland (7)    G24 (Inlier)          837
Spain         556                   11,08
Sweden        197 (Inlier)          9,192

                         Patient 2

              DRG                  Quasi price
              (In-/outliner)       (Euros)

Austria (1)   Mel05.06D (Inlier)   4,896
England (2)   GA10A (Outlier)      3,601
Estonia (3)   493 (Inlier)         847
Finland (4)   493 (Outlier)        4,91
France (5)    07C143 (Inlier)      6,222
Germany (6)   H08B (Outlier)       3,487
Ireland       H08A (Inlier)        8,768
Netherlands   110003230303         3,483
Poland (7)    G25 (Inlier)         742
Spain         493                  5,135
Sweden        493 (Inlier)         5,772

                         Patient 3

              DRG                   Quasi price
              (In-/outliner)        (Euros)

Austria (1)   Mel05.05B (Outlier)   2,191
England (2)   GA05B (Inlier)        6,344
Estonia (3)   196                   1,792
Finland (4)   194                   7,242
France (5)    07C101 (Inlier)       7,352
Germany (6)   H08B                  2,512
Ireland       H08A (Inlier)         8,768
Netherlands   110003230303          3,483
Poland (7)    G24 (Inlier)          837
Spain         787                   6,784
Sweden        196 (Inlier)          7,566

                         Patient 4

              DRG                   Quasi price
              (In-/outliner)        (Euros)

Austria (1)   Mel05.05B (Outlier)   1,382
England (2)   GA10A (Inlier)        3,085
Estonia (3)   493 (Inlier)          847
Finland (4)   494                   3,739
France (5)    07C141 (Outlier)      1,851
Germany (6)   H08B (Outlier)        1,609
Ireland       H08 (Day care)        1,689
Netherlands   110003230302          1,934
Poland (7)    G25 (Inlier)          742
Spain         493                   5,135
Sweden        4940 (Inlier)         2,431

                         Patient 5

              DRG                  Quasi price
              (In-/outliner)       (Euros)

Austria (1)   Mel05.05B (Inlier)   3,541
England (2)   GA10B (Inlier)       1,785
Estonia (3)   494                  746
Finland (4)   4940                 1,914
France (5)    07C141 (Outlier)     1,225
Germany (6)   H08B (Outlier)       1,609
Ireland       H08 (Day care)       1,689
Netherlands   110003230302         1,934
Poland (7)    G25 (Inlier)         742
Spain         494                  3,057
Sweden        4940 (Inlier)        2,431

                         Patient 6

              DRG                  Quasi price
              (In-/outliner)       (Euros)

Austria (1)   Mel05.05B (Inlier)   3,541
England (2)   GA10B (Outlier)      2,054
Estonia (3)   198 (Inlier)         1,412
Finland (4)   198                  3,134
France (5)    07C131 (Inlier)      3,470
Germany (6)   H07B                 4,603
Ireland       H07B (Inlier)        8,350
Netherlands   110003230203         5,790
Poland (7)    G25 (Inlier)         742
Spain         198                  5,114
Sweden        198 (Inlier)         7,723

DRG = Diagnosis-Related Group

(1) Reported values are based on theoretically calculated scores.
Actual hospital reimbursement depends on decisions of states,
which make use of nationwide DRG scores in different ways.
Patient 5 has a length of stay of 0 days but would NOT be
considered an outpatient.

(2) Based on 2008-9 tariff prices and HRG version 3.5. All
relevant groups are included in the shown tariff. HRG 4
reimbursements could not be determined. Reported figures are
reimbursements for emergency admissions. Elective admissions
receive a different tariff. Patient 5 has a length of stay of 0
days, but would NOT be classified as an outpatient.

(3) Shadow prices were calculated by multiplying cost weights
with the national base rates. In actual reimbursement, hospitals
are paid through a mix of DRG based reimbursement and
fee-for-service. The actual DRG based reimbursement is only 70%
of the reported shadow price with the remaining 30% being related
to fee-for-service payments.

(4) Actual reimbursement varies by type of hospital (i.e.
university, central, local hospitals) and hospital district.
Provided figures are volume weighted averages across all
hospitals. Outlier limits differ between hospital districts. In
some hospital districts, patient 3 might be considered an
outlier. In this case certain surcharges based on per diems might
be applied.

(5) Reported prices are for public sector hospitals since private
hospital prices do not reflect full costs.

(6) Calculated using national DRG cost weights and the average of
state-wide base rates.

(7) Based on 2008-9 tariff prices. Reported figures are
reimbursements for emergency admissions. Elective admissions
receive a different tariff. Patient 6 has a length of stay=0, but
would NOT be classified as an outpatient
COPYRIGHT 2014 Kerman University of Medical Sciences
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2014 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Original Article
Author:Paat-Ahi, Gerli; Aaviksoo, Ain; Swiderek, Maria
Publication:International Journal of Health Policy and Management
Article Type:Report
Date:Dec 1, 2014
Previous Article:Factors affecting family physicians' drug prescribing: a cross-sectional study in Khuzestan, Iran.
Next Article:'Only systems thinking can improve family planning program in Pakistan': a descriptive qualitative study.

Terms of use | Privacy policy | Copyright © 2020 Farlex, Inc. | Feedback | For webmasters