The impact of hospital-acquired infections on the patient-level reimbursement-cost relationship in a DRG-based hospital payment system
- 186 Downloads
Hospital-acquired infections (HAIs) are a common complication in inpatient care. We investigate the incentives to prevent HAIs under the German DRG-based reimbursement system. We analyze the relationship between resource use and reimbursements for HAI in 188,731 patient records from the University Medical Center Freiburg (2011–2014), comparing cases to appropriate non-HAI controls. Resource use is approximated using national standardized costing system data. Reimbursements are the actual payments to hospitals under the G-DRG system. Timing of HAI exposure, cost-clustering within main diagnoses and risk-adjustment are considered. The reimbursement-cost difference of HAI patients is negative (approximately − €4000). While controls on average also have a negative reimbursement-cost difference (approximately − €2000), HAI significantly increase this difference after controlling for confounding and timing of infection (− 1500, p < 0.01). HAIs caused by vancomycin-resistant Enterococci have the most unfavorable reimbursement-cost difference (− €10,800), significantly higher (− €9100, p < 0.05) than controls. Among infection types, pneumonia is associated with highest losses (− €8400 and − €5700 compared with controls, p < 0.05), while cost-reimbursement relationship for Clostridium difficile-associated diarrhea is comparatively balanced (− €3200 and − €500 compared to controls, p = 0.198). From the hospital administration’s perspective, it is not the additional costs of HAIs, but rather the cost-reimbursement relationship which guides decisions. Costs exceeding reimbursements for HAI may increase infection prevention and control efforts and can be used to show their cost-effectiveness from the hospital perspective.
KeywordsHAI G-DRG Incentives Reimbursement Cost
We would like to thank Barbara Schroeren-Boersch, Markus Dettenkofer, and Hajo Grundmann for providing the dataset, Susanne Hanser and Werner Vach for helpful comments regarding the analysis and Sabine Engler-Hüsch for technical support.
Compliance with ethical standards
Conflict of interest
This work was supported by the German Research Foundation [Grant No. WO 1746/1-2 to Martin Wolkewitz and Grant No. KA 4199/1-1 to Thomas Heister]. Klaus Kaier has received support from the Innovative Medicines Initiative Joint Undertaking under Grant Agreement No. 115737-2 (Combatting bacterial resistance in Europe—molecules against Gram negative infections [COMBACTE-MAGNET]). The funders had no role in data collection and analysis, decision to publish, or preparation of the manuscript. The authors declare no conflicts of interest.
This research involved no intervention, and all patient records were anonymized prior to use, in accordance with German data protection law. For this type of study formal consent is not required.
- Gutmann, A., Kaier, K., Sorg, S., von zur Mühlen, C., Siepe, M., Moser, M., et al. (2015). Analysis of the additional costs of clinical complications in patients undergoing transcatheter aortic valve replacement in the German Health Care System. International Journal of Cardiology,179, 231–237. https://doi.org/10.1016/j.ijcard.2014.11.095.CrossRefPubMedGoogle Scholar
- Kaier, K., Hagist, C., Frank, U., Conrad, A., & Meyer, E. (2009). Two time-series analyses of the impact of antibiotic consumption and alcohol-based hand disinfection on the incidences of nosocomial methicillin-resistant Staphylococcus aureus infection and Clostridium difficile infection. Infection Control & Hospital Epidemiology,30(4), 346–353.CrossRefGoogle Scholar
- Mitchell, B. G., & Gardner, A. (2012). Prolongation of length of stay and Clostridium difficile infection: A review of the methods used to examine length of stay due to healthcare associated infections. Antimicrobial Resistance and Infection Control,1(1), 14. https://doi.org/10.1186/2047-2994-1-14.CrossRefPubMedPubMedCentralGoogle Scholar
- Noskin, G. A., Rubin, R. J., Schentag, J. J., Kluytmans, J., Hedblom, E. C., Smulders, M., et al. (2005). The burden of Staphylococcus aureus infections on hospitals in the United States: An analysis of the 2000 and 2001 Nationwide Inpatient Sample Database. Archives of Internal Medicine,165(15), 1756–1761.CrossRefGoogle Scholar
- Quentin, W., Geissler, A., Scheller-Kreinsen, D., & Busse, R. (2010). DRG-type hospital payment in Germany: The G-DRG system. Euro Observer,12(3), 4–6.Google Scholar
- Reinöhl, J., Gutmann, A., Kollum, M., von zur Mühlen, C., Baumbach, H., Avlar, M., et al. (2013). Transfemoral aortic valve implantation: Bleeding events, related costs and outcomes. Journal of Thrombosis and Thrombolysis,35(4), 469–475. https://doi.org/10.1007/s11239-012-0829-0.CrossRefPubMedGoogle Scholar
- Wernitz, M. H., Keck, S., Swidsinski, S., Schulz, S., & Veit, S. K. (2005). Cost analysis of a hospital-wide selective screening programme for methicillin-resistant Staphylococcus aureus (MRSA) carriers in the context of diagnosis related groups (DRG) payment. Clinical Microbiology & Infection,11(6), 466–471.CrossRefGoogle Scholar
- Zimlichman, E., Henderson, D., Tamir, O., Franz, C., Song, P., Yamin, C. K., et al. (2013). Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine,173(22), 2039. https://doi.org/10.1001/jamainternmed.2013.9763.CrossRefPubMedGoogle Scholar