Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries

PubMed Central

Wittenbecher, Friedrich

2013-01-01

Abstract Objective This paper provides a comprehensive overview of hospital payment systems based on diagnosis-related groups (DRGs) in low- and middle-income countries. It also explores design and implementation issues and the related challenges countries face. Methods A literature research for papers on DRG-based payment systems in low- and middle-income countries was conducted in English, French and Spanish through Pubmed, the Pan American Health Organization’s Regional Library of Medicine and Google. Findings Twelve low- and middle-income countries have DRG-based payment systems and another 17 are in the piloting or exploratory stage. Countries have chosen from a wide range of imported and self-developed DRG models and most have adapted such models to their specific contexts. All countries have set expenditure ceilings. In general, systems were piloted before being implemented. The need to meet certain requirements in terms of coding standardization, data availability and information technology made implementation difficult. Private sector providers have not been fully integrated, but most countries have managed to delink hospital financing from public finance budgeting. Conclusion Although more evidence on the impact of DRG-based payment systems is needed, our findings suggest that (i) the greater portion of health-care financing should be public rather than private; (ii) it is advisable to pilot systems first and to establish expenditure ceilings; (iii) countries that import an existing variant of a DRG-based system should be mindful of the need for adaptation; and (iv) countries should promote the cooperation of providers for appropriate data generation and claims management. PMID:24115798

Childbirth and Diagnosis Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

PubMed

Bellanger, Martine M; Quentin, Wilm; Tan, Siok Swan

2013-05-01

The study compares how Diagnosis-Related Group (DRG) based hospital payment systems in eleven European countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) deal with women giving birth in hospitals. It aims to assist gynaecologists and national authorities in optimizing their DRG systems. National or regional databases were used to identify childbirth cases. DRG grouping algorithms and indicators of resource consumption were compared for those DRGs which account for at least 1% of all childbirth cases in the respective database. Five standardized case vignettes were defined and quasi prices (i.e. administrative prices or tariffs) of hospital deliveries according to national DRG-based hospital payment systems were ascertained. European DRG systems classify childbirth cases according to different sets of variables (between one and eight variables) into diverging numbers of DRGs (between three and eight DRGs). The most complex DRG is valued 3.5 times more resource intensive than an index case in Ireland but only 1.1 times more resource intensive than an index case in The Netherlands. Comparisons of quasi prices for the vignettes show that hypothetical payments for the most complex case amount to only € 479 in Poland but to € 5532 in Ireland. Differences in the classification of hospital childbirth cases into DRGs raise concerns whether European systems rely on the most appropriate classification variables. Physicians, hospitals and national DRG authorities should consider how other countries' DRG systems classify cases to optimize their system and to ensure fair and appropriate reimbursement. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Testing a diagnosis-related group index for skilled nursing facilities

PubMed Central

Cotterill, Philip G.

1986-01-01

Interest in case-mix measures for use in nursing home payment systems has been stimulated by the Medicare prospective payment system (PPS) for short-term acute-care hospitals. Appropriately matching payment with care needs is important to equitably compensate providers and to encourage them to admit patients who are most in need of nursing home care. The skilled nursing facility (SNF) Medicare benefit covers skilled convalescent or rehabilitative care following a hospital stay. Therefore, it might appear that diagnosis-related groups (DRG's), the basis for patient classification in PPS, could also be used for the Medicare SNF program. In this study, a DRG-based case-mix index (CMI) was developed and tested to determine how well it explains cost differences among SNF's. The results suggest that a DRG-based SNF payment system would be highly problematic. Incentives of this system would appear to discourage placement of patients who require relatively expensive care. PMID:10311674

Testing a diagnosis-related group index for skilled nursing facilities.

PubMed

Cotterill, P G

1986-01-01

Interest in case-mix measures for use in nursing home payment systems has been stimulated by the Medicare prospective payment system (PPS) for short-term acute-care hospitals. Appropriately matching payment with care needs is important to equitably compensate providers and to encourage them to admit patients who are most in need of nursing home care. The skilled nursing facility (SNF) Medicare benefit covers skilled convalescent or rehabilitative care following a hospital stay. Therefore, it might appear that diagnosis-related groups (DRG's), the basis for patient classification in PPS, could also be used for the Medicare SNF program. In this study, a DRG-based case-mix index (CMI) was developed and tested to determine how well it explains cost differences among SNF's. The results suggest that a DRG-based SNF payment system would be highly problematic. Incentives of this system would appear to discourage placement of patients who require relatively expensive care.

Hospital financial performance under the prospective payment system by type of admission: psychiatric versus medical/surgical.

PubMed Central

Freiman, M P

1990-01-01

We performed detailed simulations of DRG-based payments to general hospitals for treatment of nonexempt psychiatric and medical/surgical patients under Medicare's prospective payment system (PPS). We then compared these results to calculated costs for the same patients. Hospitals without specialized psychiatric units tend to fare better financially on their psychiatric than on their medical/surgical caseloads, although the levels of gain for these two types of patients are correlated. Hospitals with nonexempt psychiatric units generally have similar rates of gain on psychiatric and medical/surgical patients. Comparing psychiatric treatment in "scatter-bed" sites with that provided in nonexempt units, the higher rate of gain under PPS for treatment in scatter beds results largely from shorter lengths of stay. We discuss hospital behavior and the relationships between treatment of psychiatric illness under DRG-based payment and its treatment in exempt psychiatric units, which are excluded from DRG-based payment. PMID:2123839

Breast cancer surgery and diagnosis-related groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

PubMed

Scheller-Kreinsen, David; Quentin, Wilm; Geissler, Alexander; Busse, Reinhard

2013-10-01

Researchers from eleven countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their DRG systems deal with breast cancer surgery patients. DRG algorithms and indicators of resource consumption were assessed for those DRGs that individually contain at least 1% of all breast cancer surgery patients. Six standardised case vignettes were defined and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems classify breast cancer surgery patients according to different sets of classification variables into three to seven DRGs. Quasi prices for an index case treated with partial mastectomy range from €577 in Poland to €5780 in the Netherlands. Countries award their highest payments for very different kinds of patients. Breast cancer specialists and national DRG authorities should consider how other countries' DRG systems classify breast cancer patients in order to identify potential scope for improvement and to ensure fair and appropriate reimbursement. Copyright © 2012 Elsevier Ltd. All rights reserved.

[What changes for rheumatologists in the G-DRG system 2006?].

PubMed

Liedtke-Dyong, A; Fiori, W; Lakomek, H-J; Hülsemann, J L; Köneke, N; Liman, W; Roeder, N

2006-07-01

Once more, the revision of the German DRG catalogue 2006 provides for more accurate reimbursement, particularly for specialised medical services. The newly established DRG I97Z (Rheumatologische Komplexbehandlung bei Krankheiten und Störungen an Muskel-Skelett-System und Bindegewebe) for the complex and multimodal treatment of rheumatic diseases allows an accurate picture of clinical practice in specialized rheumatologic departments and hospitals. Using this specific DRG-description, it will be possible to reduce the financial pressure which results from the redistribution of budgets in the second year of the period of convergence. A precondition for the affected hospitals is to deal with budget planning and calculation of G-DRGs without calculated cost weights for 2006. In addition, this article discusses the relevance of other modifications to the G-DRG system, additional payments, the conditions for payment, the coding standards, and the classification systems for diagnosis and procedures.

Payment Reform Pilot In Beijing Hospitals Reduced Expenditures And Out-Of-Pocket Payments Per Admission.

PubMed

Jian, Weiyan; Lu, Ming; Chan, Kit Yee; Poon, Adrienne N; Han, Wei; Hu, Mu; Yip, Winnie

2015-10-01

In 2009 China announced plans to reform provider payment methods at public hospitals by moving from fee-for-service (FFS) to prospective and aggregated payment methods that included the use of diagnosis-related groups (DRGs) to control health expenditures. In October 2011 health policy makers selected six Beijing hospitals to pioneer the first DRG payment system in China. We used hospital discharge data from the six pilot hospitals and eight other hospitals, which continued to use FFS and served as controls, from the period 2010-12 to evaluate the pilot's impact on cost containment through a difference-in-differences methods design. Our study found that DRG payment led to reductions of 6.2 percent and 10.5 percent, respectively, in health expenditures and out-of-pocket payments by patients per hospital admission. We did not find evidence of any increase in hospital readmission rates or cost shifting from cases eligible for DRG payment to ineligible cases. However, hospitals continued to use FFS payments for patients who were older and had more complications than other patients, which reduced the effectiveness of payment reform. Continuous evidence-based monitoring and evaluation linked with adequate management systems are necessary to enable China and other low- and middle-income countries to broadly implement DRGs and refine payment systems. Project HOPE—The People-to-People Health Foundation, Inc.

42 CFR 412.523 - Methodology for calculating the Federal prospective payment rates.

Code of Federal Regulations, 2010 CFR

2010-10-01

.... (4) Determining the Federal prospective payment rate for each LTC-DRG. The Federal prospective payment rate for each LTC-DRG is the product of the weighting factors described in § 412.515 and the... payment rate multiplied by the relative weight of the LTC-DRG assigned for that discharge. A hospital's...

Case mix measures and diagnosis-related groups: opportunities and threats for inpatient dermatology.

PubMed

Hensen, P; Fürstenberg, T; Luger, T A; Steinhoff, M; Roeder, N

2005-09-01

The changing healthcare environment world-wide is leading to extensive use of per case payment systems based on diagnosis-related groups (DRG). The aim of this study was to examine the impact of application of different DRG systems used in the German healthcare system. We retrospectively analysed 2334 clinical data sets of inpatients discharged from an academic dermatological inpatient unit in 2003. Data were regarded as providing high coding quality in compliance with the diagnosis and procedure classifications as well as coding standards. The application of the Australian AR-DRG version 4.1, the German G-DRG version 1.0, and the German G-DRG version 2004 was considered in detail. To evaluate more specific aspects, data were broken down into 11 groups based on the principle diagnosis. DRG cost weights and case mix index were used to compare coverage of inpatient dermatological services. Economic impacts were illustrated by case mix volumes and calculation of DRG payments. Case mix index results and the pending prospective revenues vary tremendously from the application of one or another of the DRG systems. The G-DRG version 2004 provides increased levels of case mix index that encourages, in particular, medical dermatology. The AR-DRG version 4.1 and the first German DRG version 1.0 appear to be less suitable to adequately cover inpatient dermatology. The G-DRG version 2004 has been greatly improved, probably due to proceeding calculation standards and DRG adjustments. The future of inpatient dermatology is subject to appropriate depiction of well-established treatment standards.

Diagnosis-related Groups and Hospital Inpatient Federal Reimbursement.

PubMed

Rimler, Simcha B; Gale, Brian D; Reede, Deborah L

2015-10-01

To understand the complex system of reimbursement for health care services, it is helpful to have a working knowledge of the historic context of diagnosis-related groups (DRGs), as well as their utility and increasing relevance. Congress implemented the DRG system in 1983 in response to rapidly increasing health care costs. The DRG system was designed to control hospital reimbursements by replacing retrospective payments with prospective payments for hospital charges. This article explains how these payments are calculated. Every inpatient admission is classified into one of several hundred DRGs that are based on the diagnosis, complications, and comorbidities. The Centers for Medicare & Medicaid Services (CMS) assigns each DRG a weight that the CMS uses in conjunction with hospital-specific data to determine reimbursement. A population's DRGs represent the resources needed to treat the medical disorders of that population. Hospital administrators use this information to budget and plan for the future. The Affordable Care Act and other recent legislation affect medical reimbursement by altering the DRG system. Radiologic procedures in particular are affected. This legislation will give DRGs an even larger role in determining reimbursements in the coming years. © RSNA, 2015.

TRICARE revision to CHAMPUS DRG-based payment system, pricing of hospital claims. Final rule.

PubMed

2014-05-21

This Final rule changes TRICARE's current regulatory provision for inpatient hospital claims priced under the DRG-based payment system. Claims are currently priced by using the rates and weights that are in effect on a beneficiary's date of admission. This Final rule changes that provision to price such claims by using the rates and weights that are in effect on a beneficiary's date of discharge.

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

PubMed

Quentin, Wilm; Scheller-Kreinsen, David; Geissler, Alexander; Busse, Reinhard

2012-02-01

As part of the EuroDRG project, researchers from 11 countries (i.e., Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Sweden, and Spain) compared how their diagnosis-related groups (DRG) systems deal with appendectomy patients. The study aims to assist surgeons and national authorities to optimize their DRG systems. National or regional databases were used to identify hospital cases with a diagnosis of appendicitis treated with a procedure of appendectomy. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems vary widely: they classify appendectomy patients according to different sets of variables (between two and six classification variables) into diverging numbers of DRGs (between two and 11 DRGs). The most complex DRG is valued 5.1 times more resource intensive than an index case in France but only 1.1 times more resource intensive than an index case in Finland. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the most complex case vignette amount to only 1,005 in Poland but to 12,304 in France. Large variations in the classification of appendectomy patients raise concerns whether all systems rely on the most appropriate classification variables. Surgeons and national DRG authorities should consider how other countries' DRG systems classify appendectomy patients in order to optimize their DRG system and to ensure fair and appropriate reimbursement.

The variance of length of stay and the optimal DRG outlier payments.

PubMed

Felder, Stefan

2009-09-01

Prospective payment schemes in health care often include supply-side insurance for cost outliers. In hospital reimbursement, prospective payments for patient discharges, based on their classification into diagnosis related group (DRGs), are complemented by outlier payments for long stay patients. The outlier scheme fixes the length of stay (LOS) threshold, constraining the profit risk of the hospitals. In most DRG systems, this threshold increases with the standard deviation of the LOS distribution. The present paper addresses the adequacy of this DRG outlier threshold rule for risk-averse hospitals with preferences depending on the expected value and the variance of profits. It first shows that the optimal threshold solves the hospital's tradeoff between higher profit risk and lower premium loading payments. It then demonstrates for normally distributed truncated LOS that the optimal outlier threshold indeed decreases with an increase in the standard deviation.

76 FR 32815 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-06

... Hospital IPPS Inpatient prospective payment system MS-DRG Diagnosis-related group NCA National coverage... based on the ``inpatient prospective payment system'' (IPPS) described in section 1886(d) of the Act... and procedures, and payment systems. We reviewed various articles, reports, summaries, and data bases...

42 CFR 412.332 - Payment based on the hospital-specific rate.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs Determination of Transition Period Payment Rates for... (f) is determined by multiplying the applicable hospital-specific rate by the DRG weighting factor...

Medicare program; revisions to FY 2009 Medicare severity-long-term care diagnosis-related group (MS-LTC-DRG) weights. Interim final rule with comment period.

PubMed

2009-06-03

This interim final rule with comment period implements revised Medicare severity long-term care diagnosis-related group (MS-LTC-DRG) relative weights for payment under the long-term care hospital (LTCH) prospective payment system (PPS) for federal fiscal year (FY) 2009. We are revising the MS-LTC-DRG relative weights for FY 2009 due to the misapplication of our established methodology in the calculation of the budget neutrality factor. The revised FY 2009 MS-LTC-DRG relative weights are effective for the remainder of FY 2009 (that is, from June 3, 2009 through September 30, 2009).

42 CFR 412.200 - General provisions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Operating... the prospective payment system for inpatient operating costs. Except as provided in this subpart, the... for § 412.60, which deals with DRG classification and weighting factors, the provisions of subparts D...

Spinal surgery: variations in health care costs and implications for episode-based bundled payments.

PubMed

Ugiliweneza, Beatrice; Kong, Maiying; Nosova, Kristin; Huang, Kevin T; Babu, Ranjith; Lad, Shivanand P; Boakye, Maxwell

2014-07-01

Retrospective, observational. To simulate what episodes of care in spinal surgery might look like in a bundled payment system and to evaluate the associated costs and characteristics. Episode-based payment bundling has received considerable attention as a potential method to help curb the rise in health care spending and is being investigated as a new payment model as part of the Affordable Care Act. Although earlier studies investigated bundled payments in a number of surgical settings, very few focused on spine surgery, specifically. We analyzed data from MarketScan. Patients were included in the study if they underwent cervical or lumbar spinal surgery during 2000-2009, had at least 2-year preoperative and 90-day postoperative follow-up data. Patients were grouped on the basis of their diagnosis-related group (DRG) and then tracked in simulated episodes-of-care/payment bundles that lasted for the duration of 30, 60, and 90 days after the discharge from the index-surgical hospitalization. The total cost associated with each episode-of-care duration was measured and characterized. A total of 196,918 patients met our inclusion criteria. Significant variation existed between DRGs, ranging from $11,180 (30-day bundle, DRG 491) to $107,642 (30-day bundle, DRG 456). There were significant cost variations within each individual DRG. Postdischarge care accounted for a relatively small portion of overall bundle costs (range, 4%-8% in 90-day bundles). Total bundle costs remained relatively flat as bundle-length increased (total average cost of 30-day bundle: $33,522 vs. $35,165 for 90-day bundle). Payments to hospitals accounted for the largest portion of bundle costs (76%). There exists significant variation in total health care costs for patients who undergo spinal surgery, even within a given DRG. Better characterization of impacts of a bundled payment system in spine surgery is important for understanding the costs of index procedure hospital, physician services, and postoperative care on potential future health care policy decision making. N/A.

42 CFR 412.500 - Basis and scope of subpart.

Code of Federal Regulations, 2010 CFR

2010-10-01

... appropriate adjustments to that system, including adjustments to DRG weights, area wage adjustments... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long... payment system for long-term care hospitals described in section 1886(d)(1)(B)(iv) of the Act. (2) Section...

42 CFR 412.89 - Payment adjustment for certain replaced devices.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments for... implantation of the device determines the DRG assignment. (2) CMS lists the DRGs that qualify under paragraph (b)(1) of this section in the annual final rule for the hospital inpatient prospective payment system...

42 CFR 412.529 - Special payment provision for short-stay outliers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... system DRG weighting factors. (B) Is adjusted for different area wage levels based on the geographic...-related share, using the applicable hospital inpatient prospective payment system wage index value for... share of low-income patients. (iii) Hospital inpatient prospective payment system capital Federal rate...

Bundling Post-Acute Care Services into MS-DRG Payments

PubMed Central

Vertrees, James C.; Averill, Richard F.; Eisenhandler, Jon; Quain, Anthony; Switalski, James

2013-01-01

Objective A bundled hospital payment system that encompasses both acute and post-acute care has been proposed as a means of creating financial incentives in the Medicare fee-for-service system to foster care coordination and to improve the current disorganized system of post care. The objective of this study was to evaluate the statistical stability of alternative designs of a hospital payment system that includes post-acute care services to determine the feasibility of using a combined hospital and post-acute care bundle as a unit of payment. Methods The Medicare Severity-Diagnosis Related Groups (MS-DRGs) were subdivided into clinical subclasses that measured a patient's chronic illness burden to test whether a patient's chronic illness burden had a substantial impact on post-acute care expenditures. Using Medicare data the statistical performance of the MS-DRGs with and without the chronic illness subclasses was evaluated across a wide range of post-acute care windows and combinations of post-acute care service bundles using both submitted charges and Medicare payments. Results The statistical performance of the MS-DRGs as measured by R2 was consistently better when the chronic illness subclasses are included indicating that MS-DRGs by themselves are an inadequate unit of payment for post-acute care payment bundles. In general, R2 values increased as the post-acute care window length increased and decreased as more services were added to the post-acute care bundle. Discussion The study results suggest that it is feasible to develop a payment system that incorporates significant post-acute care services into the MS-DRG inpatient payment bundle. This expansion of the basic DRG payment approach can provide a strong financial incentive for providers to better coordinate care potentially leading to improved efficiency and outcome quality. PMID:24753970

[Gastroenterology in the G-DRG-System 2004].

PubMed

Bunzemeier, H; Frühmorgen, P; Caspary, W F; Roeder, N

2003-11-01

After a year of preliminary voluntarily introduction of casemix funding in hospitals in 2003 nearly every German hospital will be confronted with lump sump payments on the basis of the G-DRG system for their inpatient care starting from January 2004. To analyse weaknesses referring to gastroenterology services within the G-DRG version 1.0 the German Association for Disorders of the Digestive System and Metabolism (DGVS) and the DRG-Research-Group from the University of Muenster conducted a DRG evaluation project. In the analysis patient data from 16 hospitals were included. As a result of the project recommendations for G-DRG adjustments were generated. Those recommendations were implemented in the advancement to G-DRG version 2004. Also the International Classification of Diseases (ICD-10) was modified to ICD-10 German Modification. The classification of procedures OPS-301 was revised. The main adjustments to the G-DRG system and both classifications will be presented in this paper.

Diagnosis-related groups for stroke in Europe: patient classification and hospital reimbursement in 11 countries.

PubMed

Peltola, Mikko; Quentin, Wilm

2013-01-01

Diagnosis-related groups (DRGs) are increasingly being used for various purposes in many countries. However, there are no studies comparing different DRG systems in the care of stroke. As part of the EuroDRG project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, the Netherlands, Poland, Sweden and Spain) compared how their DRG systems deal with stroke patients. The study aims to assist clinicians and national authorities to optimize their DRG systems. National or regional databases were used to identify hospital cases with a diagnosis of stroke. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that individually represent at least 1% of stroke cases. In addition, standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems vary widely: they classify stroke patients according to different sets of variables (between 1 and 7 classification variables) into diverging numbers of DRGs (between 1 and 10 DRGs). In 6 of the countries more than half of the patients are concentrated within a single DRG. The countries' systems also vary with respect to the evaluation of different kinds of stroke patients. The most complex DRG is considered 3.8 times more resource intensive than an index case in Finland. By contrast, in England, the DRG system does not account for complex cases. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only EUR 907 in Poland but to EUR 7,881 in Ireland. Large variations in the classification of stroke patients raise concerns whether all systems rely on the most appropriate classification variables and whether the DRGs adequately reflect differences in the complexity of treating different groups of patients. Learning from other DRG systems may help in improving the national systems. Clinicians and national DRG authorities should consider how other countries' DRG systems classify stroke patients in order to optimize their DRG system and to ensure fair and appropriate reimbursement. In future, quantitative research is needed to verify whether the most important determinants of cost are considered in different patient classification systems, and whether differences between systems reflect country-specific differences in treatment patterns and, most importantly, what influence they have on patient outcomes. Copyright © 2013 S. Karger AG, Basel.

Acute myocardial infarction and diagnosis-related groups: patient classification and hospital reimbursement in 11 European countries.

PubMed

Quentin, Wilm; Rätto, Hanna; Peltola, Mikko; Busse, Reinhard; Häkkinen, Unto

2013-07-01

As part of the diagnosis related groups in Europe (EuroDRG) project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their DRG systems deal with patients admitted to hospital for acute myocardial infarction (AMI). The study aims to assist cardiologists and national authorities to optimize their DRG systems. National or regional databases were used to identify hospital cases with a primary diagnosis of AMI. Diagnosis-related group classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems vary widely: they classify AMI patients according to different sets of variables into diverging numbers of DRGs (between 4 DRGs in Estonia and 16 DRGs in France). The most complex DRG is valued 11 times more resource intensive than an index case in Estonia but only 1.38 times more resource intensive than an index case in England. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only €420 in Poland but to €7930 in Ireland. Large variation exists in the classification of AMI patients across Europe. Cardiologists and national DRG authorities should consider how other countries' DRG systems classify AMI patients in order to identify potential scope for improvement and to ensure fair and appropriate reimbursement.

Acute myocardial infarction and diagnosis-related groups: patient classification and hospital reimbursement in 11 European countries

PubMed Central

Quentin, Wilm; Rätto, Hanna; Peltola, Mikko; Busse, Reinhard; Häkkinen, Unto

2013-01-01

Aims As part of the diagnosis related groups in Europe (EuroDRG) project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their DRG systems deal with patients admitted to hospital for acute myocardial infarction (AMI). The study aims to assist cardiologists and national authorities to optimize their DRG systems. Methods and results National or regional databases were used to identify hospital cases with a primary diagnosis of AMI. Diagnosis-related group classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems vary widely: they classify AMI patients according to different sets of variables into diverging numbers of DRGs (between 4 DRGs in Estonia and 16 DRGs in France). The most complex DRG is valued 11 times more resource intensive than an index case in Estonia but only 1.38 times more resource intensive than an index case in England. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only €420 in Poland but to €7930 in Ireland. Conclusions Large variation exists in the classification of AMI patients across Europe. Cardiologists and national DRG authorities should consider how other countries' DRG systems classify AMI patients in order to identify potential scope for improvement and to ensure fair and appropriate reimbursement. PMID:23364755

Impact of the new payment system on laparoscopic appendectomy in Korea.

PubMed

Kim, Jong Wan; Shin, Dong Woo; Chae, Jin Ju; Kim, Jeong Yeon; Park, Sung Gil

2015-12-01

Korea has a nationalized health system. The aim of this study was to evaluate the impact of the Korea diagnosis related group-based prospective payment system (K-DRG/PPS) on the use of medical resources and the rate of adverse events during laparoscopic appendectomy. We included patients who underwent laparoscopic appendectomy at Dongtan Sacred Heart Hospital, Korea, between November 2012 and February 2014. The patients were divided into two groups: before-DRG/PPS or after-DRG/PPS groups. The length of the postoperative hospital stay (LOS) and medical costs were indicators of the medical resources. Medical costs included those of the initial hospital stay, outpatient clinic, readmission, and the sum of these charges. Complication and readmission rates were indicators of the rates of adverse events. After the implementation of the DRG/PPS, length of the hospital stay decreased by 10% (4.9 d before versus 4.4 d after DRG/PPS; P < 0.001). The initial hospital stay and total cost were significantly lower in the after-DRG/PPS group (both P < 0.001). The complication rates during the initial hospital stay (3.5% before versus 2.3% after DRG/PPS; P = 0.225) and the readmission rates (4.3% versus 2.5%, respectively; P = 0.227) were statistically similar. This study shows that the K-DRG/PPS for laparoscopic appendectomy had no negative effect on the rate of adverse events and reduced the use of medical resources. Further evaluation of other procedures is required to determine the overall effects of the K-DRG/PPS. Copyright © 2015 Elsevier Inc. All rights reserved.

Comparison of Medicaid Payments Relative to Medicare Using Inpatient Acute Care Claims from the Medicaid Program: Fiscal Year 2010-Fiscal Year 2011.

PubMed

Stone, Devin A; Dickensheets, Bridget A; Poisal, John A

2018-02-01

To compare Medicaid fee-for-service (FFS) inpatient hospital payments to expected Medicare payments. Medicaid and Medicare claims data, Medicare's MS-DRG grouper and inpatient prospective payment system pricer (IPPS pricer). Medicaid FFS inpatient hospital claims were run through Medicare's MS-DRG grouper and IPPS pricer to compare Medicaid's actual payment against what Medicare would have paid for the same claim. Average inpatient hospital claim payments for Medicaid were 68.8 percent of what Medicare would have paid in fiscal year 2010, and 69.8 percent in fiscal year 2011. Including Medicaid disproportionate share hospital (DSH), graduate medical education (GME), and supplemental payments reduces a substantial proportion of the gap between Medicaid and Medicare payments. Medicaid payments relative to expected Medicare payments tend to be lower and vary by state Medicaid program, length of stay, and whether payments made outside of the Medicaid claims process are included. © Health Research and Educational Trust.

Physicians' Patient Load per DRG, the Consumption of Hospital Resources, and the Incentives of the DRG Prospective Payment System.

ERIC Educational Resources Information Center

Munoz, Eric; And Others

1990-01-01

The relationship between numbers (high or low) of patients per diagnosis-related group (DRG) treated by individual physicians and hospital resource consumption of the patients at a large academic medical center was studied for the period 1985-87. The findings, although a result of many varied factors, suggest a relationship between the two…

Effects of diagnosis-related group payment system on appendectomy outcomes.

PubMed

Kim, Tae Hyun; Park, Eun-Cheol; Jang, Sung-In; Jang, Suk-Yong; Lee, Sang Ah; Choi, Jae Woo

2016-12-01

The voluntary diagnosis-related group (DRG) payment system was introduced in 2002. Since July 2013, the Korean government has mandated DRG participation for all hospitals. The main purpose of this study was to examine the effects of mandatory DRG participation on various outcome metrics for appendectomy patients. We collected inpatient DRG data for 280,062 appendectomy patients between 2007 and 2014 using the Health Insurance Review and Assessment database. We examined patient outcome metrics such as length of stay (LOS), total medical cost, spillover, and readmission rate, according to hospital size. As a result of DRG participation, the average LOS for patients decreased (adjusted ratio: 0.83 [large hospitals], 0.83 [small hospitals]; 95% confidence interval [CI]: 0.82-0.84, 0.82-0.84), the total medical costs of patients increased (adjusted ratio: 1.23 [large hospitals], 1.35 [small hospitals]; 95% CI: 1.22-1.24, 1.34-1.36), the spillover of patients increased (adjusted ratio: 2.10 [large hospitals], 2.30 [small hospitals]; 95% CI: 2.03-2.18, 2.16-2.45), and the readmission rates of appendectomy patients decreased (adjusted ratio: 0.85 [large hospitals], 0.49 [small hospitals]; 95% CI: 0.77-0.94, 0.42-0.57). The mandatory implementation of the DRG payment system in South Korea has led to significant reductions in LOS and readmission rates for appendectomy patients. However, any resulting expansion of outpatient services may result in unnecessary resource usage rather than improving medical quality. Policy makers should consider the various implications reflected by these results when considering DRGs for other diseases. Copyright © 2016 Elsevier Inc. All rights reserved.

[Complex surgical procedures in orthopedics and trauma surgery. A contribution to the proposal procedure for the DRG system in 2009].

PubMed

Flohé, S; Nabring, J; Luetkes, P; Nast-Kolb, D; Windolf, J

2008-10-01

Since the DRG system was introduced in 2003/2004 the system for remuneration has been continually modified in conjunction with input from specialized medical associations. As part of this development of the payment system, the criteria for classification of a diagnosis-related group were further expanded and new functions were added. This contribution addresses the importance of the complex surgical procedures as criteria for subdivision of the DRG case-based lump sums in orthopedics and trauma surgery.

Impact of a diagnosis-related group payment system on cesarean section in Korea.

PubMed

Kim, Seung Ju; Han, Kyu-Tae; Kim, Sun Jung; Park, Eun-Cheol; Park, Hye Ki

2016-06-01

Cesarean sections (CSs) are the most expensive method of delivery, which may affect the physician's choice of treatment when providing health services to patients. We investigated the effects of the diagnosis-related group (DRG)-based payment system on CSs in Korea. We used National Health Insurance claim data from 2011 to 2014, which included 1,289,989 delivery cases at 674 hospitals. We used a generalized estimating equation model to evaluate the association between the likelihood of cesarean delivery and the length of the DRG adoption period. A total of 477,309 (37.0%) delivery cases were performed by CSs. We found that a longer DRG adoption period was associated with a lower odds ratio of CSs (odds ratio [OR]: 0.997, 95% CI: 0.996-0.998). In addition, a longer DRG adoption period was associated with a lower odds ratio for CSs in hospitals that had voluntarily adopted the DRG system. Similar results were also observed for urban hospitals, primiparas, and those under 28 years old and over 33 years old. Our results suggest that the change in the reimbursement system was associated with a low likelihood of CSs. The impact of DRG adoption on cesarean delivery can also be expected to increase with time, as our finding provides evidence that the reimbursement system is associated with the health provider's decision to provide health services for patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Psychiatric DRGs: more risk for hospitals?

PubMed

Ehrman, C M; Funk, G; Cavanaugh, J

1989-09-01

The diagnosis related group (DRG) system, which replaced the cost-plus system of reimbursement, was implemented in 1983 by Medicare to cover medical expenses on a prospective basis. To date, the DRG system has not been applied to psychiatric illness. The authors compare the likelihood of cost overruns in psychiatric illness with that of cost overruns in medical illness. The data analysis demonstrates that a prospective payment system would have a high likelihood of failure in psychiatric illness. Possible reasons for failure include wide variations in treatments, diagnostics, and other related costs. Also, the number of DRG classifications for psychiatric illness is inadequate.

Change in MS-DRG assignment and hospital reimbursement as a result of Centers for Medicare & Medicaid changes in payment for hospital-acquired conditions: is it coding or quality?

PubMed

McNutt, Robert; Johnson, Tricia J; Odwazny, Richard; Remmich, Zachary; Skarupski, Kimberly; Meurer, Steven; Hohmann, Samuel; Harting, Brian

2010-01-01

In October 2008, the Centers for Medicare & Medicaid Services reduced payments to hospitals for a group of hospital-acquired conditions (HACs) not documented as present on admission (POA). It is unknown what proportion of Medicare severity diagnosis related group (MS-DRG) assignments will change when the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code for the HAC is not taken into account even before considering the POA status. The primary objectives were to estimate the proportion of cases that change MS-DRG assignment when HACs are removed from the calculation, the subsequent changes in reimbursement to hospitals, and the attenuation in changes in MS-DRG assignment after factoring in those that may be POA. Last, we explored the effect of the numbers of ICD-9-CM diagnosis codes on MS-DRG assignment. We obtained 2 years of discharge data from academic medical centers that were members of the University Health System Consortium and identified all cases with 1 of 7 HACs coded through ICD-9-CM diagnosis codes. We calculated the MS-DRG for each case with and without the HAC and, hence, the proportion where MS-DRG assignment changed. Next, we used a bootstrap method to calculate the range in the proportion of cases changing assignment to account for POA status. Changes in reimbursement were estimated by using the 2008 MS-DRG weights payment formula. Of 184,932 cases with at least 1 HAC, 27.6% (n = 52,272) would experience a change in MS-DRG assignment without the HAC factored into the assignment. After taking into account those conditions that were potentially POA, 7.5% (n = 14,176) of the original cases would change MS-DRG assignment, with an average loss in reimbursement per case ranging from $1548 with a catheter-associated urinary tract infection to $7310 for a surgical site infection. These reductions would translate into a total reimbursement loss of $50 261,692 (range: $38 330,747-$62 344,360) for the 86 academic medical centers. Those cases, for all conditions, with reductions in payment also have fewer additional ICD-9-CM codes associated. Removing HACs from MS-DRG assignment may result in significant cost savings for the Centers for Medicare & Medicaid Services through reduced payment to hospitals. As more conditions are added, the negative impact on hospital reimbursement may become greater. However, it is possible that variation in coding practice may affect cost savings and not reflect true differences in quality of care.

Charting a path forward: policy analysis of China's evolved DRG-based hospital payment system

PubMed Central

Liu, Rui; Shi, Jianwei; Yang, Beilei; Jin, Chunlin; Sun, Pengfei; Wu, Lingfang; Yu, Dehua; Xiong, Linping; Wang, Zhaoxin

2017-01-01

Abstract Background At present, the diagnosis-related groups-based prospective payment system (DRG-PPS) that has been implemented in China is merely a prototype called the simplified DRG-PPS, which is known as the ‘ceiling price for a single disease’. Given that studies on the effects of a simplified DRG-PPS in China have usually been controversial, we aim to synthesize evidence examining whether DRGs can reduce medical costs and length of stay (LOS) in China. Methods Data were searched from both Chinese [Wan Fang and China National Knowledge Infrastructure Database (CNKI)] and international databases (Web of Science and PubMed), as well as the official websites of Chinese health departments in the 2004–2016 period. Only studies with a design that included both experimental (with DRG-PPS implementation) and control groups (without DRG-PPS implementation) were included in the review. Results The studies were based on inpatient samples from public hospitals distributed in 12 provinces of mainland China. Among them, 80.95% (17/21) revealed that hospitalization costs could be reduced significantly, and 50.00% (8/16) indicated that length of stay could be decreased significantly. In addition, the government reports showed the enormous differences in pricing standards and LOS in various provinces, even for the same disease. Conclusions We conclude that the simplified DRGs are useful in controlling hospitalization costs, but they fail to reduce LOS. Much work remains to be done in China to improve the simplified DRG-PPS. PMID:28911128

[The German DRG system 2003-2010 from the perspective of intensive care medicine].

PubMed

Franz, Dominik; Bunzemeier, Holger; Roeder, Norbert; Reinecke, Holger

2010-01-01

Intensive care medicine is extremely heterogeneous, expensive and can only be partially planned and controlled. A correct and fair representation of intensive care medicine in the G-DRG system is an essential requirement for the use as a pricing system. From the perspective of intensive care medicine, pertinent changes of the DRG structure and differentiation of relevant parameters have been established within the G-DRG systems 2003-2010. Analysis of relevant diagnoses, medical procedures, co-payment structures and G-DRGs in the versions 2003-2010 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Since the first G-DRG system version 2003, numerous measures improved quality of case allocation of intensive care medicine. Highly relevant to the system version 2010 are duration of mechanical ventilation, the intensive care treatment complex and complicating constellations. The number of G-DRGs relevant to intensive medical care increased from n = 3 (2003) to n = 58 (2010). For standard cases, quality of case allocation and G-DRG reimbursement are adequate in 2010. The G-DRG system gained complexity again. High demands are made on correct and complete coding of complex cases. Nevertheless, further adjustments of the G-DRG system especially for cases with extremely high costs are necessary. Where the G-DRG system is unable to cover extremely high-cost cases, reimbursement solutions beyond the G-DRG structure should be taken into account.

Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

PubMed

Paat-Ahi, Gerli; Aaviksoo, Ain; Swiderek, Maria

2014-12-01

As part of the EuroDRG project, researchers from eleven countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Sweden, and Spain) compared how their Diagnosis-Related Groups (DRG) systems deal with cholecystectomy patients. The study aims to assist surgeons and national authorities to optimize their DRG systems. National or regional databases were used to identify hospital cases with a procedure of cholecystectomy. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardised case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained and compared to an index case. European DRG systems vary widely: they classify cholecystectomy patients according to different sets of variables into diverging numbers of DRGs (between two DRGs in Austria and Poland to nine DRGs in England). The most complex DRG is valued at four times more resource intensive than the index case in Ireland but only 1.3 times more resource intensive than the index case in Austria. Large variations in the classification of cholecystectomy patients raise concerns whether all systems rely on the most appropriate classification variables. Surgeons, hospital managers and national 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.

42 CFR 412.525 - Adjustments to the Federal prospective payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... its estimated costs for a patient exceed the adjusted LTC-MS-DRG payment plus a fixed-loss amount. For...-DRG relative weights that are in effect at the start of the applicable long-term care hospital...

Do diagnosis-related group-based payments incentivise hospitals to adjust output mix?

PubMed

Liang, Li-Lin

2015-04-01

This study investigates whether the diagnosis-related group (DRG)-based payment method motivates hospitals to adjust output mix in order to maximise profits. The hypothesis is that when there is an increase in profitability of a DRG, hospitals will increase the proportion of that DRG (own-price effects) and decrease those of other DRGs (cross-price effects), except in cases where there are scope economies in producing two different DRGs. This conjecture is tested in the context of the case payment scheme (CPS) under Taiwan's National Health Insurance programme over the period of July 1999 to December 2004. To tackle endogeneity of DRG profitability and treatment policy, a fixed-effects three-stage least squares method is applied. The results support the hypothesised own-price and cross-price effects, showing that DRGs which share similar resources appear to be complements rather substitutes. For-profit hospitals do not appear to be more responsive to DRG profitability, possibly because of their institutional characteristics and bonds with local communities. The key conclusion is that DRG-based payments will encourage a type of 'product-range' specialisation, which may improve hospital efficiency in the long run. However, further research is needed on how changes in output mix impact patient access and pay-outs of health insurance. Copyright © 2014 John Wiley & Sons, Ltd.

On the use of administrative databases to support planning activities: the case of the evaluation of neonatal case-mix in the Emilia-Romagna region using DRG and APR-DRG classification systems.

PubMed

Fantini, M P; Cisbani, L; Manzoli, L; Vertrees, J; Lorenzoni, L

2003-06-01

There are several versions of the Diagnosis Related Group (DRG) classification systems that are used for case-mix analysis, utilization review, prospective payment, and planning applications. The objective of this study was to assess the adequacy of two of these DRG systems--Medicare DRG and All Patient Refined DRG--to classify neonatal patients. The first part of the paper contains a descriptive analysis that outlines the major differences between the two systems in terms of classification logic and variables used in the assignment process. The second part examines the statistical performance of each system on the basis of the administrative data collected in all public hospitals of the Emilia-Romagna region relating to neonates discharged in 1997 and 1998. The Medicare DRG are less developed in terms of classification structure and yield a poorer statistical performance in terms of reduction in variance for length of stay. This is important because, for specific areas, a more refined system can prove useful at regional level to remove systematic biases in the measurement of case-mix due to the structural characteristics of the Medicare DRGs classification system.

[Diagnosis-related groups as an instrument to develop suitable case-based lump sums in hematology and oncology].

PubMed

Thalheimer, Markus

2011-01-01

In 2003 a new reimbursement system was established for German hospitals. The approximately 17 million inpatient cases per year are now reimbursed based on a per-case payment regarding diagnoses and procedures, which was developed from an internationally approved system. The aim was a better conformity of costs and efforts in in-patient cases. In the first 2 years after implementation, the German diagnosis-related group (DRG) system was not able to adequately represent the complex structures of treatment in hematological and oncological in-patients. By creating new diagnoses and procedures (International Classification of Diseases 10 (ICD-10) and Surgical Operations and Procedures Classification System (OPS) catalogues), generating new DRGs and better splitting of existing ones, the hematology and oncology field could be much better described in the following years. The implementation of about 70 'co-payment structures' for new and expensive drugs and procedures in oncology was also crucial. To reimburse innovations, an additional system of co-payments for innovations was established to bridge the time until innovations are represented within the DRG system itself. In summary, hematological and oncological in-patients, including cases with extraordinary costs, are meanwhile well mapped in the German reimbursement system. Any tendencies to rationing could thereby be avoided, as most of the established procedures and costly drugs are adequately represented in the DRG system. Copyright © 2011 S. Karger AG, Basel.

Impact of the Japanese Diagnosis Procedure Combination-based Payment System on cardiovascular medicine-related costs.

PubMed

Yasunaga, Hideo; Ide, Hiroo; Imamura, Tomoaki; Ohe, Kazuhiko

2005-09-01

In 2003, a lump-sum payment system based on Diagnosis Procedure Combinations (DPC) was introduced to 82 specific function hospitals in Japan. While the US DRG/PPS system is a "per case payment" system, the DPC based payment system adopts a "per day payment." It is generally believed that the Japanese system provides as much of an incentive as the DRG/PPS system to shorten the average length of stay (LOS). We performed an empirical analysis of the effect of LOS shortening on hospital revenue and expenditure under the DPC-based payment system, particularly in cardiovascular diseases. We also point out fundamentally controversial aspects of the current system. A total 109 cases were selected from patients hospitalized at the University of Tokyo Hospital from May to July, 2003 and classified into one of three categories: (1) cardiac catheter interventions, (2) cardiac catheter examinations, and (3) other conservative treatments. We analyzed the changes in profit per day in cases of a reduction in average LOS and an increase in the number of cases. In category (1) profit increased significantly in conjunction with reduced LOS. In category (2) profit increased only minimally. In category (3), profit increased rarely and sometimes decreased. In cases of conservative treatment, profits sometimes decreased because an increase in material costs exceeded the increase in revenue. It therefore became clear that the DPC-based payment system does not decisively provide an economic incentive to reduce LOS in cardiovascular medicine.

[Costs of appendicitis treatment by diagnosis-related groups in a third-level pediatric hospital].

PubMed

Tlacuilo-Parra, Alberto; Hernández-Hernández, Araceli; Venegas-Dávalos, Martha; Gutiérrez-Hermosillo, Violeta; Guevara-Gutiérrez, Elizabeth; Ambriz-González, Gabriela

2014-01-01

Diagnosis-related groups (DRGs) are widely used in Europe. They allow performing comparisons in hospitals and incurrent hospital payment systems, defining the payment categories. We undertook this study to classify children who underwent appendectomy according to DRGs. Cross-sectional study. Comorbidities, length of hospitalization, histopathologic classification, and DRG classifications were analyzed. We included 313 patients, 62% males, with an average age of 8 ± 3 years; 91% were referred by another hospital and 67% were treated at night. Average length of hospitalization was 4 ± 3 days. There were comorbidities in 8% and surgical complications in 11%. According to histopathology, appendicitis was edematous (11%), suppurative (36%), gangrenous (22%), perforated (29%), and abscessed (2%). At discharge, 97% of the patients were healthy. Total cost for DRG 343 was $10,470,173.00 (Mexican pesos), DRG 342 was $1,227,592.00 and DRG 340 was $511,521.00. The global amount was $12,209,286.00 (Mexican pesos). The unitary cost for treatment of appendectomy for DRG 343 was $37,935.00, for DRG 342 was $49,103.00 and for DRG 340 was $42,626.00 (Mexican pesos). Because 88% of the cases of appendicitis were uncomplicated, this amount of money could be spent to treat these patients in a second-level hospital, using reimbursement 343 without generating additional expenses.

Charting a path forward: policy analysis of China's evolved DRG-based hospital payment system.

PubMed

Liu, Rui; Shi, Jianwei; Yang, Beilei; Jin, Chunlin; Sun, Pengfei; Wu, Lingfang; Yu, Dehua; Xiong, Linping; Wang, Zhaoxin

2017-09-01

At present, the diagnosis-related groups-based prospective payment system (DRG-PPS) that has been implemented in China is merely a prototype called the simplified DRG-PPS, which is known as the 'ceiling price for a single disease'. Given that studies on the effects of a simplified DRG-PPS in China have usually been controversial, we aim to synthesize evidence examining whether DRGs can reduce medical costs and length of stay (LOS) in China. Data were searched from both Chinese [Wan Fang and China National Knowledge Infrastructure Database (CNKI)] and international databases (Web of Science and PubMed), as well as the official websites of Chinese health departments in the 2004-2016 period. Only studies with a design that included both experimental (with DRG-PPS implementation) and control groups (without DRG-PPS implementation) were included in the review. The studies were based on inpatient samples from public hospitals distributed in 12 provinces of mainland China. Among them, 80.95% (17/21) revealed that hospitalization costs could be reduced significantly, and 50.00% (8/16) indicated that length of stay could be decreased significantly. In addition, the government reports showed the enormous differences in pricing standards and LOS in various provinces, even for the same disease. We conclude that the simplified DRGs are useful in controlling hospitalization costs, but they fail to reduce LOS. Much work remains to be done in China to improve the simplified DRG-PPS. © The Author 2017. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.

Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries

PubMed Central

Paat-Ahi, Gerli; Aaviksoo, Ain; Świderek, Maria

2014-01-01

Background: As part of the EuroDRG project, researchers from eleven countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Sweden, and Spain) compared how their Diagnosis-Related Groups (DRG) systems deal with cholecystectomy patients. The study aims to assist surgeons and national authorities to optimize their DRG systems. Methods: National or regional databases were used to identify hospital cases with a procedure of cholecystectomy. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardised case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained and compared to an index case. Results: European DRG systems vary widely: they classify cholecystectomy patients according to different sets of variables into diverging numbers of DRGs (between two DRGs in Austria and Poland to nine DRGs in England). The most complex DRG is valued at four times more resource intensive than the index case in Ireland but only 1.3 times more resource intensive than the index case in Austria. Conclusion: Large variations in the classification of cholecystectomy patients raise concerns whether all systems rely on the most appropriate classification variables. Surgeons, hospital managers and national 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. PMID:25489596

DRG migration: A novel measure of inefficient surgical care in a value-based world.

PubMed

Hughes, Byron D; Mehta, Hemalkumar B; Sieloff, Eric; Shan, Yong; Senagore, Anthony J

2018-03-01

Diagnosis-Related Group (DRG) migration, DRG 331 to 330, is defined by the assignment to a higher cost DRG due only to post admission comorbidity or complications (CC). We assessed the 5% national Medicare data set (2011-2014) for colectomy (DRG's 331/330), excluding present on admission CC's and selecting patients with one or more CC's post-admission to define the impact on payments, cost, and length of stay (LOS). The incidence of DRG migration was 14.2%. This was associated with statistically significant increases in payments, hospital cost, and LOS compared to DRG 331 patients. When DRG migration rate was extrapolated to the entire at risk population, the results were an increase of Centers for Medicare and Medicaid Services (CMS) cost by $98 million, hospital cost by $418 million, and excess hospital days equaling 68,669 days. These negative outcomes represent potentially unnecessary variations in the processes of care, and therefore a unique economic concept defining inefficient surgical care. Copyright © 2017 Elsevier Inc. All rights reserved.

Diagnosis-related group-adjusted hospital costs are higher in older medical patients with lower functional status.

PubMed

Chuang, Kenneth H; Covinsky, Kenneth E; Sands, Laura P; Fortinsky, Richard H; Palmer, Robert M; Landefeld, C Seth

2003-12-01

To determine whether hospital costs are higher in patients with lower functional status at admission, defined as dependence in one or more activities of daily living (ADLs), after adjustment for Medicare Diagnosis-Related Group (DRG) payments. Prospective study. General medical service at a teaching hospital. One thousand six hundred twelve patients aged 70 and older. The hospital cost of care for each patient was determined using a cost management information system, which allocates all hospital costs to individual patients. Hospital costs were higher in patients dependent in ADLs on admission than in patients independent in ADLs on admission ($5,300 vs $4,060, P<.01). Mean hospital costs remained higher in ADL-dependent patients than in ADL-independent patients in an analysis that adjusted for DRG weight ($5,240 vs $4,140, P<.01), and in multivariate analyses adjusting for age, race, sex, Charlson comorbidity score, acute physiology and chronic health evaluation score, and admission from a nursing home as well as for DRG weight ($5,200 vs $4,220, P<.01). This difference represents a 23% (95% confidence interval=15-32%) higher cost to take care of older dependent patients. Hospital cost is higher in patients with worse ADL function, even after adjusting for DRG payments. If this finding is true in other hospitals, DRG-based payments provide hospitals a financial incentive to avoid patients dependent in ADLs and disadvantage hospitals with more patients dependent in ADLs.

Pathways to DRG-based hospital payment systems in Japan, Korea, and Thailand.

PubMed

Annear, Peter Leslie; Kwon, Soonman; Lorenzoni, Luca; Duckett, Stephen; Huntington, Dale; Langenbrunner, John C; Murakami, Yuki; Shon, Changwoo; Xu, Ke

2018-05-07

Countries in Asia are working towards achieving universal health coverage while ensuring improved quality of care. One element is controlling hospital costs through payment reforms. In this paper we review experiences in using Diagnosis Related Groups (DRG) based hospital payments in three Asian countries and ask if there is an "Asian way to DRGs". We focus first on technical issues and follow with a discussion of implementation challenges and policy questions. We reviewed the literature and worked as an expert team to investigate existing documentation from Japan, Republic of Korea, and Thailand. We reviewed the design of case-based payment systems, their experience with implementation, evidence about impact on service delivery, and lessons drawn for the Asian region. We found that countries must first establish adequate infrastructure, human resource capacity and information management systems. Capping of volumes and prices is sometimes essential along with a high degree of hospital autonomy. Rather than introduce a complete classification system in one stroke, these countries have phased in DRGs, in some cases with hospitals volunteering to participate as a first step (Korea), and in others using a blend of different units for hospital payment, including length of stay, and fee-for-service (Japan). Case-based payment systems are not a panacea. Their value is dependent on their design and implementation and the capacity of the health system. Copyright © 2018 Elsevier B.V. All rights reserved.

Effects of the per diem prospective payment system with DRG-like grouping system (DPC/PDPS) on resource usage and healthcare quality in Japan.

PubMed

Hamada, Hironori; Sekimoto, Miho; Imanaka, Yuichi

2012-10-01

In 2003, Japan introduced the prospective payment system (PPS) with diagnosis-related groups (DRG) rearranged grouping system called the diagnostic procedure combination/per-diem payment system (DPC/PDPS). Even after eight years, little is known about the effects of DPC/PDPS. The purpose of this study was to examine the effects of DPC/PDPS on resource usage and healthcare quality. Using 2001-2009 (fiscal year) administrative data of acute myocardial infarction patients, four indices, including inpatient total accumulated medical charges, length of stay (LOS), mortality rate, and readmission rate, were compared between patients reimbursed by DPC/PDPS or by fee-for-service. DPC/PDPS significantly reduced total accumulated medical charges by $1061 (95% confidence interval [CI], -2007, -116) and LOS by 2.29 days (95% CI, -3.71, -0.88) after risk adjustment. However, mortality rate (Odds ratio [OR], 0.94; 95% CI, 0.73, 1.21) was unchanged. Furthermore, DPC/PDPS increased the readmission rate (OR, 1.37; 95% CI, 1.03, 1.82). This study showed that DPC/PDPS was associated with reduced resource usage, but not improved healthcare quality, as with DRG/PPSs in other countries. To achieve successful healthcare reform, further discussion on additional motives will be required. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Use of Diagnosis-Related Groups by Non-Medicare Payers

PubMed Central

Carter, Grace M.; Jacobson, Peter D.; Kominski, Gerald F.; Perry, Mark J.

1994-01-01

Medicare's prospective payment system (PPS) for hospital cases is based on diagnosis-related groups (DRGs). A wide variety of other third-party payers for hospital care have adapted elements of this system for their own use. The extent of DRG use varies considerably both by type of payer and by geographical area. Users include: 21 State Medicaid programs, 3 workers' compensation systems, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), more than one-half of the Blue Cross and Blue Shield Association (BCBSA) member plans, several self-insured employers, and a few employer coalitions. We describe how each of these payers use DRGs. No single approach is dominant. Some payers negotiate specific prices for so many combinations of DRG and hospital that the paradigm that payment equals rate times weight does not apply. What has emerged appears to be a very flexible payment system in which the only constant is the use of DRGs as a measure of output. PMID:10142368

76 FR 72912 - TRICARE; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-28

...This notice describes the changes made to the TRICARE DRG- based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS). It also provides the updated fixed loss cost outlier threshold, cost-to-charge ratios and the data necessary to update the FY 2012 rates.

78 FR 65618 - TRICARE; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-01

...This notice describes the changes made to the TRICARE DRG- based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS). It also provides the updated fixed loss cost outlier threshold, cost-to-charge ratios, and the data necessary to update the FY 2014 rates.

77 FR 71180 - TRICARE; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Fiscal Year...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-29

...This notice describes the changes made to the TRICARE DRG- based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS). It also provides the updated fixed loss cost outlier threshold, cost-to-charge ratios and the data necessary to update the FY 2013 rates.

Why and how did Israel adopt activity-based hospital payment? The Procedure-Related Group incremental reform.

PubMed

Brammli-Greenberg, Shuli; Waitzberg, Ruth; Perman, Vadim; Gamzu, Ronni

2016-10-01

Historically, Israel paid its non-profit hospitals on a perdiem (PD) basis. Recently, like other OECD countries, Israel has moved to activity-based payments. While most countries have adopted a diagnostic related group (DRG) payment system, Israel has chosen a Procedure-Related Group (PRG) system. This differs from the DRG system because it classifies patients by procedure rather than diagnosis. In Israel, the PRG system was found to be more feasible given the lack of data and information needed in the DRG classification system. The Ministry of Health (MoH) chose a payment scheme that depends only on inhouse creation of PRG codes and costing, thus avoiding dependence on hospital data. The PRG tariffs are priced by a joint Health and Finance Ministry commission and updated periodically. Moreover, PRGs are believed to achieve the same main efficiency objectives as DRGs: increasing the volume of activity, shortening unnecessary hospitalization days, and reducing the gaps between the costs and prices of activities. The PRG system is being adopted through an incremental reform that started in 2002 and was accelerated in 2010. The Israeli MoH involved the main players in the hospital market in the consolidation of this potentially controversial reform in order to avoid opposition. The reform was implemented incrementally in order to preserve the balance of resource allocation and overall expenditures of the system, thus becoming budget neutral. Yet, as long as gaps remain between marginal costs and prices of procedures, PRGs will not attain all their objectives. Moreover, it is still crucial to refine PRG rates to reflect the severity of cases, in order to tackle incentives for selection of patients within each procedure. Copyright © 2016 The Author(s). Published by Elsevier Ireland Ltd.. All rights reserved.

[Financing of inpatient orthopedics and trauma surgery in the G-DRG system 2010].

PubMed

Franz, D; Schemmann, F; Roeder, N; Mahlke, L

2010-08-01

The German DRG (diagnosis-related groups) system forms the basis for billing inpatient hospital services. It includes not only the case groups (G-DRGs), but also additional and innovation payments. This paper analyzes and evaluates the relevant developments of the G-DRG System 2010 for orthopedics and traumatology from the medical and classification perspectives. Analyses of relevant diagnoses, medical procedures and G-DRGs in the versions 2009 and 2010 based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI) were carried out. The DRG catalog is has grown from 8 to 1,200 G-DRGs. A number of codes for surgical measures have been newly established or modified. Here, the identification and the correct and performance-based mapping of complex and elaborate scenarios was again the focus of the restructuring of the G-DRG system. The G-DRG structure in orthopedics and traumatology has been changed, especially in the areas of spinal surgery and surgery of the upper and lower extremities. The actual impact of the changes may vary depending on the individual hospital services. For the first time since the introduction of the G-DRG system, the pure numerical changes at the level of DRGs themselves are so marginal that only part of the DRG users in the hospitals will register them. The changes implemented not only a high selectivity between complex and less complex scenarios, but partly also unintended and unjustified revaluation of less complex measures. The G-DRG system has gained complexity again. Especially the G-DRG allocation of spinal surgery and multiple surgical interventions of the upper and/or lower extremities have reached such a complexity that only a few DRG users can follow them.

42 CFR 412.104 - Special treatment: Hospitals with high percentage of ESRD discharges.

Code of Federal Regulations, 2010 CFR

2010-10-01

... for classification. CMS provides an additional payment to a hospital for inpatient services provided... established that ESRD beneficiary discharges, excluding discharges classified into MS-DRG 652 (Renal Failure), MS-DRG 682 (Renal Failure with MCC), MS-DRG 683 (Renal Failure with CC), MS-DRG 684 (Renal Failure...

75 FR 79348 - TRICARE; Formerly Known as the Civilian Health and Medical Program of the Uniformed Services...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-20

...This notice describes the changes made to the TRICARE DRG- based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS). It also provides the updated fixed loss cost outlier threshold, cost-to-charge ratios and the data necessary to update the Fiscal Year 2011 rates.

42 CFR 412.428 - Publication of Updates to the inpatient psychiatric facility prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... the methodology and data used to calculate the updated Federal per diem base payment amount. (b)(1... maintain the appropriate outlier percentage. (e) Describe the ICD-9-CM coding changes and DRG... psychiatric facilities for which the fiscal intermediary obtains inaccurate or incomplete data with which to...

Coronary artery bypass grafts and diagnosis related groups: patient classification and hospital reimbursement in 10 European countries

PubMed Central

2014-01-01

Background The prospective reimbursement of hospitals through the grouping of patients into a finite number of categories (Diagnosis Related Groups, DRGs), is common to many European countries. However, the specific categories used vary greatly across countries, using different characteristics to define group boundaries and thus those characteristics which result in different payments for treatment. In order to assist in the construction and modification of national DRG systems, this study analyses the DRG systems of 10 European countries. Aims To compare the characteristics used to categorise patients receiving a coronary artery bypass graft (CABG) surgery into DRGs. Further, to compare the structure into which DRGs are placed and the relative price paid for patients across Europe. Method Patients with a procedure of CABG surgery are analysed from Austria, England, Estonia, Finland, France, Germany, Ireland, Poland, Spain and Sweden. Diagrammatic algorithms of DRG structures are presented for each country. The price in Euros of seven typical case vignettes, each made up of a set of a hypothetical patient’s characteristics, is also analysed for each country. In order to enable comparisons across countries the simplest case (index vignette) is taken as baseline and relative price levels are calculated for the other six vignettes, each representing patients with different combinations of procedures and comorbidities. Results European DRG payment structures for CABG surgery vary in terms of the number of different DRGs used and the types of distinctions which define patient categorisation. Based on the payments given to hospitals in different countries, the most resource intensive patient, relative to the index vignette, ranges in magnitude from 1.37 in Poland to 2.82 in Ireland. There is also considerable variation in how much different systems pay for particular circumstances, such as the occurrence of catheterisation or presence of comorbidity. Conclusion Past experience of the construction of DRG systems for CABG patients demonstrates the variety of options available. It also highlights the importance of updating systems as frequently as possible, to incentivise best practice. PMID:24949279

DRG systems in Europe: variations in cost accounting systems among 12 countries.

PubMed

Tan, Siok Swan; Geissler, Alexander; Serdén, Lisbeth; Heurgren, Mona; van Ineveld, B Martin; Redekop, W Ken; Hakkaart-van Roijen, Leona

2014-12-01

Diagnosis-related group (DRG)-based hospital payment systems have gradually become the principal means of reimbursing hospitals in many European countries. Owing to the absence or inaccuracy of costs related to DRGs, these countries have started to routinely collect cost accounting data. The aim of the present article was to compare the cost accounting systems of 12 European countries. A standardized questionnaire was developed to guide comprehensive cost accounting system descriptions for each of the 12 participating countries. The cost accounting systems of European countries vary widely by the share of hospital costs reimbursed through DRG payment, the presence of mandatory cost accounting and/or costing guidelines, the share of cost collecting hospitals, costing methods and data checks on reported cost data. Each of these aspects entails a trade-off between accuracy of the cost data and feasibility constraints. Although a 'best' cost accounting system does not exist, our cross-country comparison gives insight into international differences and may help regulatory authorities and hospital managers to identify and improve areas of weakness in their cost accounting systems. Moreover, it may help health policymakers to underpin the development of a cost accounting system. © The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

42 CFR 412.60 - DRG classification and weighting factors.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false DRG classification and weighting factors. 412.60... Determining Prospective Payment Federal Rates for Inpatient Operating Costs § 412.60 DRG classification and weighting factors. (a) Diagnosis-related groups. CMS establishs a classification of inpatient hospital...

42 CFR 412.60 - DRG classification and weighting factors.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false DRG classification and weighting factors. 412.60... Determining Prospective Payment Federal Rates for Inpatient Operating Costs § 412.60 DRG classification and weighting factors. (a) Diagnosis-related groups. CMS establishs a classification of inpatient hospital...

Hospital cost control in Norway: a decade's experience with prospective payment.

PubMed Central

Crane, T S

1985-01-01

Under Norway's prospective payment system, which was in existence from 1972 to 1980, hospital costs increased 15.8 percent annually, compared with 15.3 percent in the United States. In 1980 the Norwegian national government started paying for all institutional services according to a population-based, morbidity-adjusted formula. Norway's prospective payment system provides important insights into problems of controlling hospital costs despite significant differences, including ownership of medical facilities and payment and spending as a percent of GNP. Yet striking similarities exist. Annual real growth in health expenditures from 1972 to 1980 in Norway was 2.2 percent, compared with 2.4 percent in the United States. In both countries, public demands for cost control were accompanied by demands for more services. And problems of geographic dispersion of new technology and distribution of resources were similar. Norway's experience in the 1970s demonstrates that prospective payment is no panacea. The annual budget process created disincentives to hospitals to control costs. But Norway's changes in 1980 to a population-based methodology suggest a useful approach to achieve a more equitable distribution of resources. This method of payment provides incentives to control variations in both admissions and cost per case. In contrast, the Medicare approach based on Diagnostic Related Groups (DRGs) is limited, and it does not affect variations in admissions and capital costs. Population-based methodologies can be used in adjusting DRG rates to control both problems. In addition, the DRG system only applies to Medicare payments; the Norwegian experience demonstrates that this system may result in significant shifting of costs onto other payors. PMID:3927385

[Cases and duration of mechanical ventilation in German hospitals : An analysis of DRG incentives and developments in respiratory medicine].

PubMed

Biermann, A; Geissler, A

2016-09-01

Diagnosis-related groups (DRGs) have been used to reimburse hospitals services in Germany since 2003/04. Like any other reimbursement system, DRGs offer specific incentives for hospitals that may lead to unintended consequences for patients. In the German context, specific procedures and their documentation are suspected to be primarily performed to increase hospital revenues. Mechanical ventilation of patients and particularly the duration of ventilation, which is an important variable for the DRG-classification, are often discussed to be among these procedures. The aim of this study was to examine incentives created by the German DRG-based payment system with regard to mechanical ventilation and to identify factors that explain the considerable increase of mechanically ventilated patients in recent years. Moreover, the assumption that hospitals perform mechanical ventilation in order to gain economic benefits was examined. In order to gain insights on the development of the number of mechanically ventilated patients, patient-level data provided by the German Federal Statistical Office and the German Institute for the Hospital Remuneration System were analyzed. The type of performed ventilation, the total number of ventilation hours, the age distribution, mortality and the DRG distribution for mechanical ventilation were calculated, using methods of descriptive and inferential statistics. Furthermore, changes in DRG-definitions and changes in respiratory medicine were compared for the years 2005-2012. Since the introduction of the DRG-based payment system in Germany, the hours of ventilation and the number of mechanically ventilated patients have substantially increased, while mortality has decreased. During the same period there has been a switch to less invasive ventilation methods. The age distribution has shifted to higher age-groups. A ventilation duration determined by DRG definitions could not be found. Due to advances in respiratory medicine, new ventilation methods have been introduced that are less prone to complications. This development has simultaneously improved survival rates. There was no evidence supporting the assumption that the duration of mechanical ventilation is influenced by the time intervals relevant for DRG grouping. However, presumably operational routines such as staff availability within early and late shifts of the hospital have a significant impact on the termination of mechanical ventilation.

[Changes to diagnosis-related groups in urology in 2007. Urology in the G-DRG-System 2007].

PubMed

Wenke, A; Franz, D; Pühse, G; Hertle, L; Roeder, N

2008-02-01

The German DRG (dose-related groups) system is updated each year by the institution dealing with the remuneration in hospitals (InEK). Once again, the German Spcoety for Urology has supported the adjustment process in a constructive manner. Analysis of the changes and their implications is highly significant for urology. This article describes and discusses the main changes in the system for the specialty of urology insofar as they concern the structure of the DRG system and the catalogues of diagnoses (ICD) and of procedures (OPS). The 2007 edition of the DRG system leads to numerous changes for urology. There are new OPS codes for partial resection of the kidney, treatment of urinary incontinence and radical resection in the pelvis minor. Additional payment for implantation of a prosthetic penis is divided with reference to the type of prosthesis. At DRG level, new DRG splits are found depending on the PCCL and patient age. Combination operations on the bladder and bowel and on the male genitalia are assigned to newly established DRGs. The changes described enhance the professional accuracy of the representations of urological care provision. New strategies designed to solve problems in representation have been established (e.g. multi-step interventions). Various problems persist, e.g. those of operations on the penis (DRG M03Z) and the need for more finely defined representation of laser treatment in urology. In the short term practicable solutions to the problem of improving the quality of representation are needed.

Rural implications of Medicare's post-acute-care transfer payment policy.

PubMed

Schoenman, Julie A; Mueller, Curt D

2005-01-01

Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the full DRG payment only when the patient's length of stay (LOS) is short relative to the geometric mean LOS for the DRG; otherwise, the full DRG payment is received. This policy originally applied to 10 DRGs beginning in fiscal year 1999 and was expanded to additional DRGs in FY2004. The Secretary may include other DRGs and types of PAC settings in future expansions. This article examines how the initial policy change affected rural and urban hospitals and investigates the likely impact of the FY2004 expansion and other possible future expansions. The authors used 1998-2001 Medicare Provider Analysis and Review (MEDPAR) data to investigate changes in hospital discharge patterns after the original policy was implemented, compute the change in Medicare revenue resulting from the payment change, and simulate the expected revenue reductions under expansions to additional DRGs and swing-bed discharges. Neither rural nor urban hospitals appear to have made a sustained change in their discharge behavior so as to limit their exposure to the transfer policy. Financial impacts from the initial policy were similar in relative terms for both types of hospitals and would be expected to be fairly similar for an expansion to additional DRGs. On average, including swing-bed discharges in the transfer policy would have a very small financial impact on small rural hospitals; only hospitals that make extensive use of swing beds after a short inpatient stay might expect large declines in total Medicare revenue. Rural hospitals are not disproportionately harmed by the PAC transfer policy. An expanded policy may even benefit rural hospitals by recognizing their lower use of post-acute-care and readjusting DRG weights so that they are paid more appropriately when providing the full course of inpatient care.

Bayesian logistic regression approaches to predict incorrect DRG assignment.

PubMed

Suleiman, Mani; Demirhan, Haydar; Boyd, Leanne; Girosi, Federico; Aksakalli, Vural

2018-05-07

Episodes of care involving similar diagnoses and treatments and requiring similar levels of resource utilisation are grouped to the same Diagnosis-Related Group (DRG). In jurisdictions which implement DRG based payment systems, DRGs are a major determinant of funding for inpatient care. Hence, service providers often dedicate auditing staff to the task of checking that episodes have been coded to the correct DRG. The use of statistical models to estimate an episode's probability of DRG error can significantly improve the efficiency of clinical coding audits. This study implements Bayesian logistic regression models with weakly informative prior distributions to estimate the likelihood that episodes require a DRG revision, comparing these models with each other and to classical maximum likelihood estimates. All Bayesian approaches had more stable model parameters than maximum likelihood. The best performing Bayesian model improved overall classification per- formance by 6% compared to maximum likelihood, with a 34% gain compared to random classification, respectively. We found that the original DRG, coder and the day of coding all have a significant effect on the likelihood of DRG error. Use of Bayesian approaches has improved model parameter stability and classification accuracy. This method has already lead to improved audit efficiency in an operational capacity.

[Definition of polytrauma in the German DRG system 2006. Up to 30% "incorrect classifications"].

PubMed

Flohé, S; Buschmann, C; Nabring, J; Merguet, P; Luetkes, P; Lefering, R; Nast-Kolb, D; Ruchholtz, S

2007-07-01

Severely injured patients represent a relevant financial cost factor in the health system especially for high level trauma centres. The introduction of a"diagnosis-related group" (DRG) system in Germany further revealed the potential negative economic impact of severely injured patients for trauma centres. In recent years several changes of the specific DRG for severely injured patients occurred with the aim of a convenient reimbursement for the trauma patient. The present study analysed 38 multiply injured patients admitted in the first half of the year 2004. These patients were analysed in terms of the respective DRG that was attributed to the patient on the basis of the definition criteria for 2004 and 2005. In addition for the same patient group the total inpatient treatment costs were calculated according to the algorithm developed by the Working Group on Polytrauma of the German Trauma Society. The analysis revealed three major problems in the reimbursement for severely injured patients according to the German DRG system: (1) In spite of the additional payment for blood compounds on top of the DRG reimbursement in 2005 a mean economic deficit of more than 4000 euro remains for each severely injured patient. (2) In 30% of the analysed trauma patients the combination of the diagnosis and operations did not lead to a specific polytrauma DRG or to an intensive care medicine DRG. (3) In the patients that could not be attributed to a polytrauma DRG, the economic deficit was with an average of more than 9000 euro even higher. This attribution aspect is also currently relevant, since the definition criteria for a polytrauma DRG were not changed in 2006 or 2007. We conclude that besides the recent changes in the reimbursement for polytrauma DRGs, which have been at least partly adapted to the real financial burden of these patients, the definition of a severely injured patient in the German DRG system may also need to be revised.

Structure and performance of different DRG classification systems for neonatal medicine.

PubMed

Muldoon, J H

1999-01-01

There are a number of Diagnosis-Related Group (DRG) classification systems that have evolved over the past 2 decades, each with their own strengths and weaknesses. DRG systems are used for case-mix trending, utilization management and quality improvement, comparative reporting, prospective payment, and price negotiations. For any of these applications it is essential to know the accuracy with which the DRG system classifies patients, specifically for predicting resource use and also mortality. The objective of this study was to assess the adequacy of the three most commonly used DRG systems for neonatal patients-Medicare DRGs, All Patient Diagnosis-Related Groups (AP-DRGs), and All Patient Refined Diagnosis-Related Groups (APR-DRGs). A 2-part methodology is used to assess adequacy. The first part is a descriptive analysis that examines the structural characteristics of each system. This provides a framework for understanding the inherent strengths and weaknesses of each system and for interpreting their statistical performance. The second part examines the statistical performance of each system on a large nationally representative hospital database. The analysis identifies major differences in the structure and statistical performance of the three DRG systems for neonates. The Medicare DRGs are structurally the least developed and yield the poorest overall statistical performance (cost R2 = 0.292; mortality R2 = 0.083). The APR-DRGs are structurally the most developed and yield the best statistical performance (cost R2 = 0.627; mortality R2 = 0.416). The AP-DRGs are intermediate to Medicare DRGs and APR-DRGs, although closer to APR-DRGs (cost R2 = 0.507; mortality R2 = 0.304). An analysis of payment impacts and systematic effects identifies there are major systematic biases with the Medicare DRGs. At the patient level, there is substantial underpayment for surgical neonates, transferred-in neonates, neonates discharged to home health services, and neonates who die. In contrast, there is substantial overpayment for normal newborns. At the facility level, there is substantial underpayment for freestanding acute children's hospitals and major teaching general hospitals. There is overpayment for other urban general hospitals but this pattern varies by hospital size. There is very substantial overpayment for other rural hospitals. The AP-DRGs remove the majority of the systematic effects but significant biases remain. The APR-DRGs remove most of the systematic effects but some biases remain.

How recalibration method, pricing, and coding affect DRG weights

PubMed Central

Carter, Grace M.; Rogowski, Jeannette A.

1992-01-01

We compared diagnosis-related group (DRG) weights calculated using the hospital-specific relative-value (HSR V) methodology with those calculated using the standard methodology for each year from 1985 through 1989 and analyzed differences between the two methods in detail for 1989. We provide evidence suggesting that classification error and subsidies of higher weighted cases by lower weighted cases caused compression in the weights used for payment as late as the fifth year of the prospective payment system. However, later weights calculated by the standard method are not compressed because a statistical correlation between high markups and high case-mix indexes offsets the cross-subsidization. HSR V weights from the same files are compressed because this methodology is more sensitive to cross-subsidies. However, both sets of weights produce equally good estimates of hospital-level costs net of those expenses that are paid by outlier payments. The greater compression of the HSR V weights is counterbalanced by the fact that more high-weight cases qualify as outliers. PMID:10127456

75 FR 60417 - Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-30

...-related groups (DRGs). The CHAMPUS DRG-based payment system, except for children's hospitals (whose capital and direct medical education costs are incorporated in the children's hospital differential), who... direct medical education costs. Respondents are institutional providers. Affected Public: Business or...

Knee replacement and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

PubMed

Tan, Siok Swan; Chiarello, Pietro; Quentin, Wilm

2013-11-01

Researchers from 11 countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their Diagnosis-Related Group (DRG) systems deal with knee replacement cases. The study aims to assist knee surgeons and national authorities to optimize the grouping algorithm of their DRG systems. National or regional databases were used to identify hospital cases treated with a procedure of knee replacement. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97 % of cases. Five standardized case scenarios were defined and quasi-prices according to national DRG-based hospital payment systems ascertained. Grouping algorithms for knee replacement vary widely across countries: they classify cases according to different variables (between one and five classification variables) into diverging numbers of DRGs (between one and five DRGs). Even the most expensive DRGs generally have a cost index below 2.00, implying that grouping algorithms do not adequately account for cases that are more than twice as costly as the index DRG. Quasi-prices for the most complex case vary between euro 4,920 in Estonia and euro 14,081 in Spain. Most European DRG systems were observed to insufficiently consider the most important determinants of resource consumption. Several countries' DRG system might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities. Ultimately, this would contribute to assuring adequate performance comparisons and fair hospital reimbursement on the basis of DRGs.

Refining Risk Adjustment for the Proposed CMS Surgical Hip and Femur Fracture Treatment Bundled Payment Program.

PubMed

Cairns, Mark A; Ostrum, Robert F; Clement, R Carter

2018-02-21

The U.S. Centers for Medicare & Medicaid Services (CMS) has been considering the implementation of a mandatory bundled payment program, the Surgical Hip and Femur Fracture Treatment (SHFFT) model. However, bundled payments without appropriate risk adjustment may be inequitable to providers and may restrict access to care for certain patients. The SHFFT proposal includes adjustment using the Diagnosis-Related Group (DRG) and geographic location. The goal of the current study was to identify and quantify patient factors that could improve risk adjustment for SHFFT bundled payments. We retrospectively reviewed a 5% random sample of Medicare data from 2008 to 2012. A total of 27,898 patients were identified who met SHFFT inclusion criteria (DRG 480, 481, and 482). Reimbursement was determined for each patient over the bundle period (the surgical hospitalization and 90 days of post-discharge care). Multivariable regression was performed to test demographic factors, comorbidities, geographic location, and specific surgical procedures for associations with reimbursement. The average reimbursement was $23,632 ± $17,587. On average, reimbursements for male patients were $1,213 higher than for female patients (p < 0.01). Younger age was also associated with higher payments; e.g., reimbursement for those ≥85 years of age averaged $2,282 ± $389 less than for those aged 65 to 69 (p < 0.01). Most comorbidities were associated with higher reimbursement, but dementia was associated with lower payments, by an average of $2,354 ± $243 (p < 0.01). Twenty-two procedure codes are included in the bundle, and patients with the 3 most common codes accounted for 98% of the cases, with average reimbursement ranging from $22,527 to $24,033. Less common procedures varied by >$20,000 in average reimbursement (p < 0.01). DRGs also showed significant differences in reimbursement (p < 0.01); e.g., DRG 480 was reimbursed by an average of $10,421 ± $543 more than DRG 482. Payments varied significantly by state (p ≤ 0.01). Risk adjustment incorporating specific comorbidities demonstrated better performance than with use of DRG alone (r = 0.22 versus 0.15). Our results suggest that the proposed SHFFT bundled payment model should use more robust risk-adjustment methods to ensure that providers are reimbursed fairly and that patients retain access to care. At a minimum, payments should be adjusted for age, comorbidities, demographic factors, geographic location, and surgical procedure.

[The quality of patient care under the German DRG system using as example the inguinal hernia repair].

PubMed

Rudroff, C; Schweins, M; Heiss, M M

2008-02-01

The DRG system in Germany was introduced to improve and at the same time simplify the reimbursement of costs in German hospitals. Cost effectiveness and economic efficiency were the declared goals. Structural changes and increased competition among different hospitals were the consequences. The effect on the qualitiy of patient care has been discussed with some concern. Furthermore, doubts have been expressed about the correct representation of the various diagnoses and treatments in the coding system and the financial revenue. Inguinal hernia repair serves as an example to illustrate some common problems with the reimbursement in the DRG system. Virtual patients were grouped using a "Web Grouper" and analysed using the cost accounting from the G-DRG-Browser of the InEK. Additionally, the reimbursement for ambulant hernia repair was estimated. The DRG coding did not differentiate the various operative procedures for inguinal hernia repair. They all generated the same revenues. For example, the increased costs for bilateral inguinal hernia repair are not represented in the payment. Furthermore, no difference is made between primary and recurrent inguinal hernia. In the case of a short-term hospital stay, part of the revenue is retained. In the case of ambulatory treatment of inguinal hernia, the reimbursement is by far not a real compensation for the actual costs. The ideal patient in the DRG system suffers from a primary inguinal hernia, undergoes an open hernia repair without mesh, and remains for 2-3 days in hospital. Minimally invasive procedures, repair of bilateral inguinal hernia and ambulant operation are by far less profitable--if at all. The current revenues for inguinal hernia repair require improvement and adjustment to reality in order to accomplish the goals which the DRG system in Germany aims at.

Medicare payment system for hospital inpatients: diagnosis-related groups.

PubMed

Baker, Judith J

2002-01-01

Diagnosis-Related Groups (DRGs) are categories of patient conditions that demonstrate similar levels of hospital resources required to treat the conditions. Each inpatient that is discharged from an acute care hospital can be classified into one of the 506 DRGs currently utilized by the Medicare program. The Medicare DRG prospective payment methodology has been in use for almost two decades and is used by hospital managers for planning and decisionmaking. The viability of DRGs for future prospective payment depends on the ability to keep up with the times through updates of the current methodology.

After the revolution: DRGs at age 30.

PubMed

Quinn, Kevin

2014-03-18

1 October 2013 marked 30 years since Medicare began paying hospitals by diagnosis-related group (DRG), arguably the most influential innovation in the history of health care financing. Initially developed as a tool for hospital management, DRGs became the basis of the inpatient prospective payment system that Medicare implemented in 1983. The strong incentives were revolutionary in their impact. Medicare spending growth slowed sharply, and, more remarkable, hospitals posted record profits. After the link between cost and payment was broken, hospitals moved quickly to cut costs. Nevertheless, a literature survey concluded that none of the worst fears about adverse effects on patients were realized. Diagnosis-related groups have also come to define "the product of a hospital" for purposes of benchmarking and risk adjustment. The acceptance of DRG algorithms owes much to their categorical approach, clinical focus, and transparency. The 2 most commonly used algorithms, Medicare DRGs and All Patient Refined (APR) DRGs, typically explain more than 40% of cost variance in inpatient stays, although with considerable range by care category. Because Medicare DRGs are unsuitable for obstetrics, pediatrics, and neonatology, some payers prefer APR DRGs. Diagnosis-related groups have proven to be a suitable basis for payment, as evidenced by widespread use. Common issues include mitigation of adverse incentives, appropriate payment for extremely costly stays, applicability to certain hospitals and care categories, and growing complexity. The DRG experience offers lessons about the effectiveness of financial incentives, the likelihood of adverse effects, the usefulness of case-mix measures, the risks of growing complexity, and the example that sensible policy need not be the domain of any one political party or other entity.

20 CFR 10.810 - How are payments for inpatient medical services determined?

Code of Federal Regulations, 2010 CFR

2010-04-01

... services determined? 10.810 Section 10.810 Employees' Benefits OFFICE OF WORKERS' COMPENSATION PROGRAMS... for inpatient medical services determined? (a) OWCP will pay for inpatient medical services according... the form of the DRG Grouper software program. On this list, each DRG represents the average resources...

Orthopedics coding and funding.

PubMed

Baron, S; Duclos, C; Thoreux, P

2014-02-01

The French tarification à l'activité (T2A) prospective payment system is a financial system in which a health-care institution's resources are based on performed activity. Activity is described via the PMSI medical information system (programme de médicalisation du système d'information). The PMSI classifies hospital cases by clinical and economic categories known as diagnosis-related groups (DRG), each with an associated price tag. Coding a hospital case involves giving as realistic a description as possible so as to categorize it in the right DRG and thus ensure appropriate payment. For this, it is essential to understand what determines the pricing of inpatient stay: namely, the code for the surgical procedure, the patient's principal diagnosis (reason for admission), codes for comorbidities (everything that adds to management burden), and the management of the length of inpatient stay. The PMSI is used to analyze the institution's activity and dynamism: change on previous year, relation to target, and comparison with competing institutions based on indicators such as the mean length of stay performance indicator (MLS PI). The T2A system improves overall care efficiency. Quality of care, however, is not presently taken account of in the payment made to the institution, as there are no indicators for this; work needs to be done on this topic. Copyright © 2014. Published by Elsevier Masson SAS.

78 FR 10579 - TRICARE Revision to CHAMPUS DRG-Based Payment System, Pricing of Hospital Claims

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-14

... order and the assessment of the impact on Claims Operations, Customer Service, Provider Administration... are following Medicare and industry standards. There are known cost impacts associated with this... have other substantial impacts. It has been certified that this rule is not economically significant...

Reimbursement of care for severe trauma under SwissDRG.

PubMed

Moos, Rudolf M; Sprengel, Kai; Jensen, Kai Oliver; Jentzsch, Thorsten; Simmen, Hans-Peter; Seifert, Burkhardt; Ciritsis, Bernhard; Neuhaus, Valentin; Volbracht, Jörk; Mehra, Tarun

2016-01-01

Treatment of patients with severe injuries is costly, with best results achieved in specialised care centres. However, diagnosis-related group (DRG)-based prospective payment systems have difficulties in depicting treatment costs for specialised care. We analysed reimbursement of care for severe trauma in the first 3 years after the introduction of the Swiss DRG reimbursement system (2012-2014). The study included all patients with solely basic insurance, hospital admission after 01.01.2011 and discharge in 2011 or 2012, who were admitted to the resuscitation room of the University Hospital of Zurich, aged ≥16 years and with an injury severity score (ISS) ≥16 (n = 364). Clinical, financial and administrative data were extracted from the electronic medical records. All cases were grouped into DRGs according to different SwissDRG versions. We considered results to be significant if p ≤0.002. The mean deficit decreased from 12 065 CHF under SwissDRG 1.0 (2012) to 2 902 CHF under SwissDRG 3.0 (2014). The main reason for the reduction of average deficits was a refinement of the DRG algorithm with a regrouping of 23 cases with an ISS ≥16 from MDC 01 to DRGs within MDC21A. Predictors of an increased total loss per case could be identified: for example, high total number of surgical interventions, surgeries on multiple anatomical regions or operations on the pelvis (p ≤0.002). Psychiatric diagnoses in general were also significant predictors of deficit per case (p<0.001). The reimbursement for care of severely injured patients needs further improvement. Cost neutral treatment was not possible under the first three versions of SwissDRG.

[Development of a set of nursing-sensitive indicators for Swiss practice].

PubMed

Kleinknecht-Dolf, Michael; Baumberger, Dieter; Jucker, Thomas; Kliem, Uwe; Zimmermann, Natalie; Spirig, Rebecca

2016-02-01

The SwissDRG prospective payment system is known to inadequately account for nursing intensity due to the DRG group criteria insufficiently describing the variability of nursing intensity within individual diagnosis-related groups. In order to allow for appropriate reimbursement and resource allocation, nursing intensity must be able to be explicitly quantified and accounted for. The aim of this project was to develop a set of nursing-sensitive indicators intended to reduce the variation within individual diagnosis-related groups, supplementary to existing SwissDRG group criteria. The approach comprised a variety of methods. A systematic literature review, input from an advisory board and an expert panel, as well as three focus group interviews with nurses and nurse managers formed the basis for the synthesis of data and information gathered from these sources. A set of 14 nursing-sensitive indicators was developed. The indicators are intended to improve the homogeneity of nursing intensity within SwissDRG diagnosis-related groups. Before these nursing indicators can be adopted as group criteria, they must be formulated to conform with SwissDRG and tested empirically. This set of indicators can be seen at as a first step towards nursing intensity being adequately represented in SwissDRG diagnosis-related groups. The next challenge to be met is operationalising the indicators in codable form.

38 CFR 17.55 - Payment for authorized public or private hospital care.

Code of Federal Regulations, 2011 CFR

2011-07-01

..., not to exceed the full DRG rate as provided in paragraph (a) of this section. The hospital that... section. (c) VA shall pay the providing facility the full DRG-based rate or reasonable cost, without... each discharge, an amount to cover the non-Federal hospital's capital-related costs, kidney, heart and...

38 CFR 17.55 - Payment for authorized public or private hospital care.

Code of Federal Regulations, 2013 CFR

2013-07-01

..., not to exceed the full DRG rate as provided in paragraph (a) of this section. The hospital that... section. (c) VA shall pay the providing facility the full DRG-based rate or reasonable cost, without... each discharge, an amount to cover the non-Federal hospital's capital-related costs, kidney, heart and...

38 CFR 17.55 - Payment for authorized public or private hospital care.

Code of Federal Regulations, 2012 CFR

2012-07-01

..., not to exceed the full DRG rate as provided in paragraph (a) of this section. The hospital that... section. (c) VA shall pay the providing facility the full DRG-based rate or reasonable cost, without... each discharge, an amount to cover the non-Federal hospital's capital-related costs, kidney, heart and...

38 CFR 17.55 - Payment for authorized public or private hospital care.

Code of Federal Regulations, 2010 CFR

2010-07-01

..., not to exceed the full DRG rate as provided in paragraph (a) of this section. The hospital that... section. (c) VA shall pay the providing facility the full DRG-based rate or reasonable cost, without... each discharge, an amount to cover the non-Federal hospital's capital-related costs, kidney, heart and...

38 CFR 17.55 - Payment for authorized public or private hospital care.

Code of Federal Regulations, 2014 CFR

2014-07-01

..., not to exceed the full DRG rate as provided in paragraph (a) of this section. The hospital that... section. (c) VA shall pay the providing facility the full DRG-based rate or reasonable cost, without... each discharge, an amount to cover the non-Federal hospital's capital-related costs, kidney, heart and...

Development of lengths of stay and DRG cost weights in dermatology from 2003 to 2006.

PubMed

Wenke, Andreas; Müller, Marcel L; Babapirali, Judith; Rompel, Rainer; Hensen, Peter

2009-08-01

The G-DRG per case payments are calculated annually on the basis of present output and cost data provided from German hospitals. The economic valuation of dermatology-related DRGs depends largely on inpatients' length of stay. At present, longitudinal analyses of dermatologic hospital data considering the development of length of stay under DRG conditions are not available. A multicenter, longitudinal study of clinical data from hospitals with different care levels was performed (n = 23). Frequent and relevant dermatologic diagnoses were grouped and analyzed over a time period of four years (2003-2006). The development of lengths of stay and of G-DRG cost weights were studied in detail. Descriptive statistical methods were applied. After introduction of DRG, the data reveal a) reduction of length of stay in inpatient dermatology and b) after an initial abrupt rise, DRG valuation of dermatologic groups moderately decreased over time. Both trends changed most rapidly in the early years but reached a stable niveau in 2006. The study furthermore points out that not only length of stay, but also other type of costs influence DRG calculations. German dermatology reflects the international trend showing reductions of length of stay after introduction of a DRG-based hospital funding system. The DRG calculation and valuation of inpatient services depend on the duration of hospital stay. However, increasing per diem costs resulting from higher performances of every inpatient bed day are also taken into account. Further reduction of length of stay must not threaten the quality of inpatient care in dermatology.

The impact of DRGs on the cost and quality of health care in the United States.

PubMed

Davis, C; Rhodes, D J

1988-01-01

The prospective Payment System (PPS) represents a fundamental change in the way the United States government reimburses hospitals for medical services covered under Medicare, a federal health care insurance program for the elderly and disabled. PPS replaced the retrospective cost-based system of payment for Medicare services with a prospective payment system. Under PPS, a predetermined specific rate for each discharge dictates payment according to the diagnosis related group (DRG) in which the discharge is classified. The PPS was intended to create financial incentives that encourage hospitals to restrain the use of resources while providing high-quality inpatient care. Both objectives appear to have been met under PPS. Hospital utilization has declined, average length of stay has fallen, and the locus of care has shifted from the inpatient setting to less costly outpatient settings. The growth in inpatient hospital benefits has slowed and the impending insolvency of the Medicare trust fund has been forestalled. Studies have found no deterioration in the quality of care rendered to Medicare beneficiaries. Neither the mortality rate nor the rate of re-admission (presumably related to premature discharge) increased under PPS. Indeed, PPS appears to have enhanced the quality of inpatient care by discouraging unnecessary and potentially harmful procedures, and by encouraging the concentration of complex procedures in facilities in which the high frequency of these procedures promotes efficiency. Incentive-based reimbursement also appears to have contributed to the growth in alternative delivery systems, such as HMOs and PPOs, which contain costs by maintaining a high volume of a limited range of services. The success of the PPS/DRG system in controlling costs and promoting quality in this country suggests its application in other countries, either as a method of reimbursement or as a product line management tool.

Improving and Measuring Inpatient Documentation of Medical Care within the MS-DRG System: Education, Monitoring, and Normalized Case Mix Index

PubMed Central

Rosenbaum, Benjamin P.; Lorenz, Robert R.; Luther, Ralph B.; Knowles-Ward, Lisa; Kelly, Dianne L.; Weil, Robert J.

2014-01-01

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the “normalized case mix index,” that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved. PMID:25214820

Improving and measuring inpatient documentation of medical care within the MS-DRG system: education, monitoring, and normalized case mix index.

PubMed

Rosenbaum, Benjamin P; Lorenz, Robert R; Luther, Ralph B; Knowles-Ward, Lisa; Kelly, Dianne L; Weil, Robert J

2014-01-01

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the "normalized case mix index," that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved.

[Treatment aspects of unstable angina. Costs and payments for DRG].

PubMed

Brunelli, C; Spallarossa, P; Pasdera, A; Bezante, G P; Zorzet, F; Rossettin, P

1998-01-01

Patients with unstable angina fall into a wide prognostic and therapeutic spectrum but, in general, have great access to specialty care and invasive procedures. In the modern era, in which admissions for unstable angina outnumber those for myocardial infarction, and growing economic pressures are placed on health care systems, cardiologists must re-examine clinical strategies for treating unstable angina in the light of health-cost accounting. The aims of the present study were to examine the current management of patients admitted to our cardiology department and to calculate the medical costs. A patient schedule was drawn up to prospectively register the number and type of cardiac processes carried out during hospitalization for all unstable angina patients in the period between March 1st and May 30th, 1995. Time (minutes) actually spent by both physicians and nurses for each cardiac process were carefully recorded in order to calculate the activity budget. The effective economic budget was built for each cardiac process taking into account salaries, consumable supplies, equipment service contracts, depreciation and indirect medical and non medical costs for CCU and ward. Based to the Diagnosis Related Groups (DRG) system, 53 out of 318 patients (16%) were admitted with documented or suspected unstable angina and allocated to discharge into four DRGs: DRG 140-medically treated unstable angina: 18 patients; DRG 124-unstable angina with angiography: 16 patients; DRG 122-unstable angina evolving in myocardial infarction: 6 patients; DRG 112-unstable angina with angioplasty: 13 patients. The mean cost for hospitalized patient with unstable angina was 5,574,958 Italian Liras (DRG 140 = 2,687,719; DRG 124 = 2,800,347; DRG 122 = 6,086,563; DRG 112 = 12,751,454). The difference in costs was essentially related to the procedures involved in medical care, DRGs with expensive cardiac processes having higher costs. Furthermore, these data show a deep discrepancy between "real" costs and current DRG reimbursement. In conclusion, data show the standard management of unstable angina at our center; calculating the true costs of unstable angina is the first step towards maximizing resources and optimizing benefits.

42 CFR 412.208 - Puerto Rico rates for Federal fiscal year 1988.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 2 2014-10-01 2014-10-01 false Puerto Rico rates for Federal fiscal year 1988. 412... Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico § 412.208 Puerto Rico rates for Federal fiscal year 1988. (a) General rule. CMS determines the Puerto Rico adjusted DRG...

42 CFR 412.208 - Puerto Rico rates for Federal fiscal year 1988.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 2 2012-10-01 2012-10-01 false Puerto Rico rates for Federal fiscal year 1988. 412... Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico § 412.208 Puerto Rico rates for Federal fiscal year 1988. (a) General rule. CMS determines the Puerto Rico adjusted DRG...

42 CFR 412.208 - Puerto Rico rates for Federal fiscal year 1988.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Puerto Rico rates for Federal fiscal year 1988. 412... Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico § 412.208 Puerto Rico rates for Federal fiscal year 1988. (a) General rule. CMS determines the Puerto Rico adjusted DRG...

42 CFR 412.208 - Puerto Rico rates for Federal fiscal year 1988.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Puerto Rico rates for Federal fiscal year 1988. 412... Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico § 412.208 Puerto Rico rates for Federal fiscal year 1988. (a) General rule. CMS determines the Puerto Rico adjusted DRG...

Two-part payments for the reimbursement of investments in health technologies.

PubMed

Levaggi, Rosella; Moretto, Michele; Pertile, Paolo

2014-04-01

The paper studies the impact of alternative reimbursement systems on two provider decisions: whether to adopt a technology whose provision requires a sunk investment cost and how many patients to treat with it. Using a simple economic model we show that the optimal pricing policy involves a two-part payment: a price equal to the marginal cost of the patient whose benefit of treatment equals the cost of provision, and a separate payment for the partial reimbursement of capital costs. Departures from this scheme, which are frequent in DRG tariff systems designed around the world, lead to a trade-off between the objective of making effective technologies available to patients and the need to ensure appropriateness in use. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Aging: GAO Activities in Fiscal Year 1985.

DTIC Science & Technology

1985-12-01

Fee Schedule for Laboratory Services * Survey of HCFA’s Ongoing Efforts to Assure the Appropriateness of Medicare DRG Payment Rates * Review of New...unnecessary expenditures for prosthetic lenses and related Reduce Medicare professional services used after the removal of cataracts and inequitable Payments...Requirements for Evaluating the Impacts of Medicare Pro- spective Payment on Post-Hospital Long-Term-Care Services : Prelimi- nary Report (GAO/PEMD-85

Diagnosis related group costs in a regulated environment. A note about their economic interpretation.

PubMed

Le Pen, C; Berdeaux, G

2000-02-01

The availability of the Diagnosis Related Group (DRG) system for determining hospital costs in some European countries has encouraged its use in pharmacoeconomic evaluations. The DRG system was developed in the US to provide data for prospective payments for hospitals. However, the financing of hospitals in some European countries is still based on the so-called 'global budget' approach. Therefore, results of pharmacoeconomic studies involving hospitals financed by the 'global-budget' approach in which DRG costs have been used require careful consideration. The main points to consider are: (i) that most of the cost components constituting the DRGs are in fact charges fixed by the government. This cost-charge ratio varies significantly across different DRGs, altering economic consequences when cost-shifting between DRGs; (ii) that there is rarely a perfect concordance between attributable cost (as proposed by the DRGs) and the definition of variable cost (as defined in economic evaluations); (iii) from the Sickness Fund's point of view, the way DRGs could be interpreted is rather unclear: financing or bench-marking?; and (iv) the perspective of DRG cost is a mixed patient-hospital perspective which is neither the societal nor the health insurance perspective generally used in pharmacoeconomic evaluations. In conclusion, the use of DRG costs is a major improvement for pharmacoeconomic evaluation. However, many hypotheses still need to be made in these studies, depending on the economic perspective of the study. Therefore, the results of pharmacoeconomic studies should be considered and discussed in line with the national financing system of the hospitals involved.

Patient classification tool in home health care.

PubMed

Pavasaris, B

1989-01-01

Medicare's system of diagnosis related groups for health care cost reimbursements is inadequate for the special requirements of home health care. A visiting nurses association's patient classification tool correlates a meticulous record of professional time spent per patient with patient diagnosis and level of care, aimed at helping policymakers develop a more equitable DRG-based prospective payment formula for home care costs.

Forecasting the Future Reimbursement System of Korean National Health Insurance: A Contemplation Focusing on Global Budget and Neo-KDRG-Based Payment Systems

PubMed Central

2012-01-01

With the adoption of national health insurance in 1977, Korea has been utilizing fee-for-service payment with contract-based healthcare reimbursement system in 2000. Under the system, fee-for-service reimbursement has been accused of augmenting national healthcare expenditure by excessively increasing service volume. The researcher examined in this paper two major alternatives including diagnosis related group-based payment and global budget to contemplate the future of reimbursement system of Korean national health insurance. Various literature and preceding studies on pilot project and actual implementation of Neo-KDRG were reviewed. As a result, DRG-based payment was effective for healthcare cost control but low in administrative efficiency. Global budget may be adequate for cost control and improving the quality of healthcare and administrative efficiency. However, many healthcare providers disagree that excess care arising from fee-for-service payment alone has led to financial deterioration of national health insurance and healthcare institutions should take responsibility with global budget payment as an appropriate solution. Dissimilar payment systems may be applied to different types of institutions to reflect their unique attributes, and this process can be achieved step-by-step. Developing public sphere among the stakeholders and striving for consensus shall be kept as collateral to attain the desirable reimbursement system in the future. PMID:22661867

Forecasting the future reimbursement system of Korean National Health Insurance: a contemplation focusing on global budget and Neo-KDRG-based payment systems.

PubMed

Kim, Yang-Kyun

2012-05-01

With the adoption of national health insurance in 1977, Korea has been utilizing fee-for-service payment with contract-based healthcare reimbursement system in 2000. Under the system, fee-for-service reimbursement has been accused of augmenting national healthcare expenditure by excessively increasing service volume. The researcher examined in this paper two major alternatives including diagnosis related group-based payment and global budget to contemplate the future of reimbursement system of Korean national health insurance. Various literature and preceding studies on pilot project and actual implementation of Neo-KDRG were reviewed. As a result, DRG-based payment was effective for healthcare cost control but low in administrative efficiency. Global budget may be adequate for cost control and improving the quality of healthcare and administrative efficiency. However, many healthcare providers disagree that excess care arising from fee-for-service payment alone has led to financial deterioration of national health insurance and healthcare institutions should take responsibility with global budget payment as an appropriate solution. Dissimilar payment systems may be applied to different types of institutions to reflect their unique attributes, and this process can be achieved step-by-step. Developing public sphere among the stakeholders and striving for consensus shall be kept as collateral to attain the desirable reimbursement system in the future.

Adjustment of inpatient care reimbursement for nursing intensity.

PubMed

Welton, John M; Zone-Smith, Laurie; Fischer, Mary H

2006-11-01

The Centers for Medicare and Medicaid Services has begun an ambitious recalibration of the inpatient prospective payment system, the first since its introduction in 1983. Unfortunately, inpatient nursing care has been overlooked in the new payment system and continues to be treated as a fixed cost and billed at a set per-diem "room and board" fee despite the known variability of nursing intensity across different care settings and diagnoses. This article outlines the historical influences regarding costing, billing, and reimbursement of inpatient nursing care and provides contemporary evidence about the variability of nursing intensity and costs at acute care hospitals in the United States. A remedy is proposed to overcome the existing limitations of the Inpatient Prospective Payment System by creating a new nursing cost center and nursing intensity adjustment by DRG for each routine-and intensive-care day of stay to allow independent costing, billing, and reimbursement of inpatient nursing care.

[Comparison of hand surgery in the German and Italian DRG systems].

PubMed

Lotter, O; Dolderer, J; Stahl, S; Atzei, A; Haerle, M; Schaller, H E

2011-12-01

Diagnosis-related groups (DRGs) are a patient classification system grouping related types of patients treated to the resources they consumed. In this analysis we compared the Italian and the German DRG systems regarding hand surgery with an emphasis on reimbursement of clinical cases. The 15 most common hand surgical diagnoses and their corresponding operative treatment in our clinic in 2009 were processed using a DRG grouper. The underlying data were transferred to the Italian system. Thus, the length of stay and the reimbursement of both countries could be obtained and compared. The latter was adjusted and corrected by the purchasing power of each country. The mean of the upper threshold of length of stay was 10 days in the German as well as the Italian system whereas the median was 2 times higher in Italy (6 vs. 12 days). Fifteen out of 19 cases showed higher reimbursement in Germany. The case mix index (CMI) of 0.917 in Germany represents a mean payment of 2,676 € per case. In Italy the hypothetical CMI of 0.635 resulted in a mean reimbursement of 1,853 € per case. The biggest difference in remuneration could be found for replantation of multiple fingers. For this service the German health-care system pays 12,320 € more than the Italian. Total proceeds of the top 15 diagnoses applying the number of cases treated in our clinic revealed 1.7 million € in the German and 1.2 million € in the Italian DRG system. Considering the purchasing power utilizing consumer prize parities, the difference of reimbursement between the countries decreased to 300,000 €. There is no mean length of stay per DRG in Italy, only the upper threshold of length of stay is determined. In most cases the latter is higher in Italy compared to Germany. The consumption of resources for finger replantation is not adequately represented in the Italian DRG system compared to finger amputation. Reimbursement of inpatient care is influenced by multiple factors not being subject to the free market economy. For this reason only descriptive comparison is feasible. © Georg Thieme Verlag KG Stuttgart · New York.

Implications of prospective payment under DRGs for hospital marketing.

PubMed

Folland, S; Ziegenfuss, J T; Chao, P

1988-12-01

The authors analyze the hospital marketing implications of Medicare's prospective payment system under DRGs. They take an appropriately broad view of marketing and consider related impacts on culture, structure, and management, in addition to the traditional marketing mix. The article serves to present in one place the ideas and discussions on the subject from a wide and disparate literature. The aim throughout is to identify those marketing responses warranting recommendation. The recommendations are assembled in a concluding section. Though many of the ideas are not new, they have yet to be widely adopted by hospitals. Hence they represent untapped marketing opportunities attributable to the advent of the DRG system. The authors conclude with suggestions for future research.

42 CFR § 512.100 - EPM episodes being tested.

Code of Federal Regulations, 2010 CFR

2017-10-01

... SERVICES (CONTINUED) HEALTH CARE INFRASTRUCTURE AND MODEL PROGRAMS EPISODE PAYMENT MODEL Episode Payment Model Participants § 512.100 EPM episodes being tested. (a) Initiation of an episode. An episode is... under an EPM anchor MS-DRG and, in the case of the AMI model, with an AMI ICD-10-CM diagnosis code if...

The evolution of diagnosis-related groups (DRGs): from its beginnings in case-mix and resource use theory, to its implementation for payment and now for its current utilization for quality within and outside the hospital.

PubMed

Goldfield, Norbert

2010-01-01

Policymakers are searching for ways to control health care costs and improve quality. Diagnosis-related groups (DRGs) are by far the most important cost control and quality improvement tool that governments and private payers have implemented. This article reviews why DRGs have had this singular success both in the hospital sector and, over the past 10 years, in ambulatory and managed care settings. Last, the author reviews current trends in the development and implementation of tools that have the key ingredients of DRG success: categorical clinical model, separation of the clinical model from payment weights, separate payment adjustments for nonclinical factors, and outlier payments. Virtually all current tools used to manage health care costs and improve quality do not have these characteristics. This failure explains a key reason for the failure, for example, of the Medicare Advantage program to control health care costs. This article concludes with a discussion of future developments for DRG-type models outside the hospital sector.

Comparison of alternative relative weights for diagnosis-related groups

PubMed Central

Cotterill, Philip; Bobula, Joel; Connerton, Rose

1986-01-01

During this study, we investigated the extent to which diagnosis-related group (DRG) relative weights based exclusively on charge data differ from DRG weights constructed according to the methodology used in deriving the original relative weights for the Medicare prospective payment system (PPS). The PPS operating cost weights were based on a combination of cost and adjusted charge information (Pettengill and Vertrees, 1982). The results of this study reveal only minor differences between the two sets of weights. Interhospital differences in cost-to-charge ratios do not produce large, arbitrary differences between charge-based and operating cost weights. Whether the data are standardized for differences in capital and medical education costs also appears to make little difference. PMID:10311495

[Consistency and Reliability of MDK Expertise Examining the Encoding in the German DRG System].

PubMed

Gaertner, T; Lehr, F; Blum, B; van Essen, J

2015-09-01

Hospital inpatient stays are reimbursed on the basis of German diagnosis-related groups (G-DRG). The G-DRG classification system is based on complex coding guidelines. The Medical Review Board of the Statutory Health Insurance Funds (MDK) examines the encoding by hospitals and delivers individual expertises on behalf of the German statutory health insurance companies in cases in which irregularities are suspected. A study was conducted on the inter-rater reliability of the MDK expertises regarding the scope of the assessment. A representative sample of 212 MDK expertises was taken from a selected pool of 1 392 MDK expertises in May 2013. This representative sample underwent a double-examination by 2 independent MDK experts using a special software based on the 3MTM G-DRG Grouper 2013 of 3M Medica, Germany. The following items encoded by the hospitals were examined: DRG, principal diagnosis, secondary diagnoses, procedures and additional payments. It was analysed whether the results of MDK expertises were consistent, reliable and correct. 202 expertises were eligible for evaluation, containing a total of 254 questions regarding one or more of the 5 items encoded by hospitals. The double-examination by 2 independent MDK experts showed matching results in 187 questions (73.6%) meaning they had been examined consistently and correctly. 59 questions (23.2%) did not show matching results, nevertheless they had been examined correctly regarding the scope of the assessment. None of the principal diagnoses was significantly affected by inconsistent or wrong judgment. A representative sample of MDK expertises examining the DRG encoding by hospitals showed a very high percentage of correct examination by the MDK experts. Identical MDK expertises cannot be achieved in all cases due to the scope of the assessment. Further improvement and simplification of codes and coding guidelines are required to reduce the scope of assessment with regard to correct DRG encoding and its examination. © Georg Thieme Verlag KG Stuttgart · New York.

42 CFR 412.312 - Payment based on the Federal rate.

Code of Federal Regulations, 2013 CFR

2013-10-01

...) Payment adjustments—(1) DRG weights. The relative resource requirements of the discharge are taken into... urban area set forth at § 412.63(c)(6) continues to be in effect for discharges occurring on or after... share adjustment. For hospitals with at least 100 beds located in an urban area and serving low-income...

42 CFR 412.312 - Payment based on the Federal rate.

Code of Federal Regulations, 2014 CFR

2014-10-01

...) Payment adjustments—(1) DRG weights. The relative resource requirements of the discharge are taken into... urban area set forth at § 412.63(c)(6) continues to be in effect for discharges occurring on or after... share adjustment. For hospitals with at least 100 beds located in an urban area and serving low-income...

42 CFR 412.312 - Payment based on the Federal rate.

Code of Federal Regulations, 2012 CFR

2012-10-01

...) Payment adjustments—(1) DRG weights. The relative resource requirements of the discharge are taken into... urban area set forth at § 412.63(c)(6) continues to be in effect for discharges occurring on or after... share adjustment. For hospitals with at least 100 beds located in an urban area and serving low-income...

48 CFR 1602.170-7 - Experience-rate.

Code of Federal Regulations, 2013 CFR

2013-10-01

... groups, including mental health benefits capitation rates, per diems, and DRG payments. [70 FR 31378... EMPLOYEES HEALTH BENEFITS ACQUISITION REGULATION GENERAL DEFINITIONS OF WORDS AND TERMS Definitions of FEHBP...

48 CFR 1602.170-7 - Experience-rate.

Code of Federal Regulations, 2011 CFR

2011-10-01

... groups, including mental health benefits capitation rates, per diems, and DRG payments. [70 FR 31378... EMPLOYEES HEALTH BENEFITS ACQUISITION REGULATION GENERAL DEFINITIONS OF WORDS AND TERMS Definitions of FEHBP...

48 CFR 1602.170-7 - Experience-rate.

Code of Federal Regulations, 2010 CFR

2010-10-01

... groups, including mental health benefits capitation rates, per diems, and DRG payments. [70 FR 31378... HEALTH BENEFITS ACQUISITION REGULATION GENERAL DEFINITIONS OF WORDS AND TERMS Definitions of FEHBP Terms...

48 CFR 1602.170-7 - Experience-rate.

Code of Federal Regulations, 2012 CFR

2012-10-01

... groups, including mental health benefits capitation rates, per diems, and DRG payments. [70 FR 31378... EMPLOYEES HEALTH BENEFITS ACQUISITION REGULATION GENERAL DEFINITIONS OF WORDS AND TERMS Definitions of FEHBP...

Implications of DRG Classification in a Bundled Payment Initiative for COPD.

PubMed

Parekh, Trisha M; Bhatt, Surya P; Westfall, Andrew O; Wells, James M; Kirkpatrick, Denay; Iyer, Anand S; Mugavero, Michael; Willig, James H; Dransfield, Mark T

2017-12-01

Institutions participating in the Medicare Bundled Payments for Care Improvement (BPCI) initiative invest significantly in efforts to reduce readmissions and costs for patients who are included in the program. Eligibility for the BPCI initiative is determined by diagnosis-related group (DRG) classification. The implications of this methodology for chronic diseases are not known. We hypothesized that patients included in a BPCI initiative for chronic obstructive pulmonary disease (COPD) would have less severe illness and decreased hospital utilization compared with those excluded from the bundled payment initiative. Retrospective observational study. We sought to determine the clinical characteristics and outcomes of Medicare patients admitted to the University of Alabama at Birmingham Hospital with acute exacerbations of COPD between 2012 and 2014 who were included and excluded in a BPCI initiative. Patients were included in the analysis if they were discharged with a COPD DRG or with a non-COPD DRG but with an International Classification of Diseases, Ninth Revision code for COPD exacerbation. Six hundred and ninety-eight unique patients were discharged for an acute exacerbation of COPD; 239 (34.2%) were not classified into a COPD DRG and thus were excluded from the BPCI initiative. These patients were more likely to have intensive care unit (ICU) admissions (63.2% vs 4.4%, respectively; P <.001) and require noninvasive (46.9% vs 6.5%; P <.001) and invasive mechanical ventilation (41.4% vs 0.7%; P <.001) during their hospitalization than those in the initiative. They also had a longer ICU length of stay (5.2 vs 1.8 days; P = .011), longer hospital length of stay (10.3 days vs 3.9 days; P <.001), higher in-hospital mortality (14.6% vs 0.7%; P <.001), and greater hospitalization costs (median = $13,677 [interquartile range = $7489-$23,054] vs $4281 [$2718-$6537]; P <.001). The use of DRGs to identify patients with COPD for inclusion in the BPCI initiative led to the exclusion of more than one-third of patients with acute exacerbations who had more severe illness and worse outcomes and who may benefit most from the additional interventions provided by the initiative.

Implications of DRG Classification in a Bundled Payment Initiative for COPD

PubMed Central

PAREKH, TRISHA M.; BHATT, SURYA P.; WESTFALL, ANDREW O.; WELLS, JAMES M.; KIRKPATRICK, DENAY; IYER, ANAND S.; MUGAVERO, MICHAEL; WILLIG, JAMES H.; DRANSFIELD, MARK T.

2018-01-01

OBJECTIVES Institutions participating in the Medicare Bundled Payments for Care Improvement (BPCI) initiative invest significantly in efforts to reduce readmissions and costs for patients who are included in the program. Eligibility for the BPCI initiative is determined by diagnosis-related group (DRG) classification. The implications of this methodology for chronic diseases are not known. We hypothesized that patients included in a BPCI initiative for chronic obstructive pulmonary disease (COPD) would have less severe illness and decreased hospital utilization compared with those excluded from the bundled payment initiative. STUDY DESIGN Retrospective observational study. METHODS We sought to determine the clinical characteristics and outcomes of Medicare patients admitted to the University of Alabama at Birmingham Hospital with acute exacerbations of COPD between 2012 and 2014 who were included and excluded in a BPCI initiative. Patients were included in the analysis if they were discharged with a COPD DRG or with a non-COPD DRG but with an International Classification of Diseases, Ninth Revision code for COPD exacerbation. RESULTS Six hundred and ninety-eight unique patients were discharged for an acute exacerbation of COPD; 239 (34.2%) were not classified into a COPD DRG and thus were excluded from the BPCI initiative. These patients were more likely to have intensive care unit (ICU) admissions (63.2% vs 4.4%, respectively; P <.001) and require noninvasive (46.9% vs 6.5%; P <.001) and invasive mechanical ventilation (41.4% vs 0.7%; P <.001) during their hospitalization than those in the initiative. They also had a longer ICU length of stay (5.2 vs 1.8 days; P = .011), longer hospital length of stay (10.3 days vs 3.9 days; P <.001), higher in-hospital mortality (14.6% vs 0.7%; P <.001), and greater hospitalization costs (median = $13,677 [interquartile range = $7489-$23,054] vs $4281 [$2718-$6537]; P <.001). CONCLUSIONS The use of DRGs to identify patients with COPD for inclusion in the BPCI initiative led to the exclusion of more than one-third of patients with acute exacerbations who had more severe illness and worse outcomes and who may benefit most from the additional interventions provided by the initiative. PMID:29623307

The debate over diagnosis related groups.

PubMed

Spiegel, A D; Kavaler, F

1985-01-01

With the advent of the Prospective Payment System (PPS) using Diagnosis Related Groups (DRGs) as a classification method, the pros and cons of that mechanism have been sharply debated. Grouping the comments into categories related to administration/management, DRG system and quality of care, a review of relevant literature highlights the pertinent attitudes and views of professionals and organizations. Points constantly argued include data utilization, meaningful medical classifications, resource use, gaming, profit centers, patient homogeneity, severity of illness, length of stay, technology limitations and the erosion of standards.

The revised burn diagram and its effect on diagnosis-related group coding.

PubMed

Turner, D G; Berger, N; Weiland, A P; Jordan, M H

1996-01-01

Diagnosis-related group (DRG) codes for burn injuries are defined by thresholds of the percentage of total body surface area and depth of burns, and by whether surgery, debridement, or grafting or both occurred. This prospective study was designed to determine whether periodic revisions of the burn diagram resulted in more accurate assignment of the International Classification of Diseases and DRG codes. The admission burn diagrams were revised after admission and after each surgical procedure. All areas grafted (deep second-and third-degree burns) were diagrammed as "third-degree," after the current convention that both are biologically the same and require grafting. The multiple diagrams from 82 charts were analyzed to determine the disparities in the percentage of total body surface area burn and the percentage of body surface area third-degree burn. The revised diagrams differed from the admission diagrams in 96.5% of the cases. In 77% of the cases, the revised diagram correctly depicted the percentage of body surface area third-degree burn as confirmed intraoperatively. In 7.3% of the cases, diagram revision changed the DRG code. Documenting wound evolution in this manner allows more accurate assignment of the International Classification of Diseases and DRG codes, assuring optimal reimbursement under the prospective payment system.

Hospital inpatient prospective payment system: incorporating new technology.

PubMed

Durthaler, Jeffrey M; Miller, Alicia

2003-11-01

New technologies in the impatient prospective payment system are discussed. On December 21, 2000, Congress passed Public Law 106-554 that includes a requirement to establish a mechanism to more expeditiously incorporate the costs and establish qualifying criteria for payment of new services and technologies into the hospital inpatient prospective payment system. The final ruling of this law states that a new service or technology must demonstrate substantial improvement, be inadequately paid under the DRG system, and be "new." The intent of these criteria is to identify new technologies that offer substantial improvement over existing technologies and to provide supplemental payment that encourages physicians and hospitals to utilize the new technology. In November 2001, drotrecogin alfa (activated) received fast-track FDA approval because of the robust findings from the PROWESS trial. Drotrecogin alfa (activated) is the first agent proven to reduce mortality in patients suffering from severe sepsis associated with acute organ dysfunction who are at a high risk of death (i.e., APACHE II score > 24). In August 2002, drotrecogin alfa (activated) was one of four such new technologies and the first agent approved for new technology payment under the prospective payment system (PPS). This decision offers confidence that the PPS is effectively striving to incorporate new medical services and technologies at a pace similar to that of innovation. Providers may receive up to $3400 in additional reimbursement when drotrecogin alfa (activated) is administered in the Medicare population. Pharmacy and patient accounting personnel should develop a collaborative process to identify, document, and capture this new source of payment.

DRG benchmarking study establishes national coding norms.

PubMed

Vaul, J H

1998-05-01

With the increase in fraud and abuse investigations, healthcare financial managers should examine their organization's medical record coding procedures. The Federal government and third-party payers are looking specifically for improper billing of outpatient services, unbundling of procedures to increase payment, assigning higher-paying DRG codes for inpatient claims, and other abuses. A recent benchmarking study of Medicare Provider Analysis and Review (MEDPAR) data has established national norms for hospital coding and case mix based on DRGs and has revealed the majority of atypical coding cases fall into six DRG pairs. Organizations with a greater percentage of atypical cases--those more likely to be scrutinized by Federal investigators--will want to conduct suitable review and be sure appropriate documentation exists to justify the coding.

Return-on-Investment (ROI) Analyses of an Inpatient Lay Health Worker Model on 30-Day Readmission Rates in a Rural Community Hospital.

PubMed

Cardarelli, Roberto; Bausch, Gregory; Murdock, Joan; Chyatte, Michelle Renee

2017-07-07

The purpose of the study was to assess the return-on-investment (ROI) of an inpatient lay health worker (LHW) model in a rural Appalachian community hospital impacting 30-day readmission rates. The Bridges to Home (BTH) study completed an evaluation in 2015 of an inpatient LHW model in a rural Kentucky hospital that demonstrated a reduction in 30-day readmission rates by 47.7% compared to a baseline period. Using the hospital's utilization and financial data, a validated ROI calculator specific to care transition programs was used to assess the ROI of the BTH model comparing 3 types of payment models including Diagnosis Related Group (DRG)-only payments, pay-for-performance (P4P) contracts, and accountable care organizations (ACOs). The BTH program had a -$0.67 ROI if the hospital had only a DRG-based payment model. If the hospital had P4P contracts with payers and 0.1% of its annual operating revenue was at risk, the ROI increased to $7.03 for every $1 spent on the BTH program. However, if the hospital was an ACO as was the case for this study's community hospital, the ROI significantly increased to $38.48 for every $1 spent on the BTH program. The BTH model showed a viable ROI to be considered by community hospitals that are part of an ACO or P4P program. A LHW care transition model may be a cost-effective alternative for impacting excess 30-day readmissions and avoiding associated penalties for hospital systems with a value-based payment model. © 2017 National Rural Health Association.

Development of a claim review and payment model utilizing diagnosis related groups under the Korean health insurance.

PubMed

Shin, Y S; Yeom, Y K; Hwang, H

1993-02-01

This paper describes the development of a claim review and payment model utilizing the diagnosis related groups (DRGs) for the fee for service-based payment system of the Korean health insurance. The present review process, which examines all claims manually on a case-by-case basis, has been considered to be inefficient, costly, and time-consuming. Differences in case mix among hospitals are controlled in the proposed model using the Korean DRGs. They were developed by modifying the US-DRG system. An empirical test of the model indicated that it can enhance the efficiency as well as the credibility and objectivity of the claim review. Furthermore, it is expected that it can contribute effectively to medical cost containments and to optimal practice pattern of hospitals by establishing a useful mechanism in monitoring the performance of hospitals. However, the performance of this model needs to be upgraded by refining the Korean DRGs which play a key role in the model.

Comparison of alternative weight recalibration methods for diagnosis-related groups

PubMed Central

Rogowski, Jeannette Roskamp; Byrne, Daniel J.

1990-01-01

In this article, alternative methodologies for recalibration of the diagnosis-related group (DRG) weights are examined. Based on 1984 data, cost and charge-based weights are less congruent than those calculated with 1981 data. Previous studies using 1981 data demonstrated that cost- and charge-based weights were not very different. Charge weights result in higher payments to surgical DRGs and lower payments to medical DRGs, relative to cost weights. At the provider level, charge weights result in higher payments to large urban hospitals and teaching hospitals, relative to cost weights. PMID:10113568

Bundled Payments for Care Improvement

PubMed Central

Hardin, Lauran; Kilian, Adam; Murphy, Elizabeth

2017-01-01

BACKGROUND The Centers for Medicare and Medicaid Services Innovation Center introduced the Bundled Payments for Care Improvement (BPCI) initiative in 2011 as 1 strategy to encourage healthcare organizations and clinicians to improve healthcare delivery for patients, both when they are in the hospital and after they are discharged. Mercy Health Saint Mary’s, a large urban academic medical center, engaged in BPCI primarily with a group of medical diagnosis-related groups (DRGs). OBJECTIVES In this article, we describe our experience creating a system of response for the diverse people and diagnoses that fall into the medical DRG bundles and specifically identify organizational factors for enabling successful implementation of bundled payments. RESULTS Our experience suggests that interprofessional collaboration enabled program success. CONCLUSIONS Although still in its early phases, observations from our program’s strategies and tactics may provide potential insights for organizations considering engagement in the BPCI initiative. PMID:28509721

The diagnosis related groups enhanced electronic medical record.

PubMed

Müller, Marcel Lucas; Bürkle, Thomas; Irps, Sebastian; Roeder, Norbert; Prokosch, Hans-Ulrich

2003-07-01

The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians' coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources. Within the Electronic Medical Record (EMR) a user interface ('DRG Control Center') for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well. With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.

Using computerised patient-level costing data for setting DRG weights: the Victorian (Australia) cost weight studies.

PubMed

Jackson, T

2001-05-01

Casemix-funding systems for hospital inpatient care require a set of resource weights which will not inadvertently distort patterns of patient care. Few health systems have very good sources of cost information, and specific studies to derive empirical cost relativities are themselves costly. This paper reports a 5 year program of research into the use of data from hospital management information systems (clinical costing systems) to estimate resource relativities for inpatient hospital care used in Victoria's DRG-based payment system. The paper briefly describes international approaches to cost weight estimation. It describes the architecture of clinical costing systems, and contrasts process and job costing approaches to cost estimation. Techniques of data validation and reliability testing developed in the conduct of four of the first five of the Victorian Cost Weight Studies (1993-1998) are described. Improvement in sampling, data validity and reliability are documented over the course of the research program, the advantages of patient-level data are highlighted. The usefulness of these byproduct data for estimation of relative resource weights and other policy applications may be an important factor in hospital and health system decisions to invest in clinical costing technology.

Funding Intensive Care - Approaches in Systems Using Diagnosis-Related Groups.

PubMed

Ettelt, Stefanie; Nolte, Ellen

2012-01-01

This article summarizes a review of approaches to funding intensive care in health systems that use activity-based payment mechanisms based on diagnosis-related groups (DRGs) to reimburse hospital care in Australia (Victoria), Denmark, France, Germany, Italy, Spain, Sweden and the United States (Medicare). The study aims to inform the current debate about options for funding intensive care services for adults, children and newborns in England. Mechanisms of funding intensive care services tend to fall into three broad categories: (1) those that fund intensive care through DRGs as part of one episode of hospital care only (US Medicare, Germany, selected regions in Sweden and Italy; (2) those that use DRGs in combination with co-payments (Victoria, France); and (3) those that exclude intensive care from DRG funding and use an alternative form of payment, for example global budgets (Spain) or per diems (South Australia). The review suggests that there is no obvious example of "best practice" or dominant approach used by a majority of systems. Each approach has advantages and disadvantages, particularly in relation to the financial risk involved in providing intensive care. While the risk of underfunding intensive care may be highest in systems that apply DRGs to the entire episode of hospital care, including intensive care, concerns about potential underfunding were voiced in all systems reviewed here. Arrangements for additional funding in the form of co-payments or surcharges may reduce the risk of underfunding. However, these approaches also face the difficulty of determining the appropriate level of (additional) payment and balancing the incentive effect arising from higher payment.

Casemix classification payment for sub-acute and non-acute inpatient care, Thailand.

PubMed

Khiaocharoen, Orathai; Pannarunothai, Supasit; Zungsontiporn, Chairoj; Riewpaiboon, Wachara

2010-07-01

There is a need to develop other casemix classifications, apart from DRG for sub-acute and non-acute inpatient care payment mechanism in Thailand. To develop a casemix classification for sub-acute and non-acute inpatient service. The study began with developing a classification system, analyzing cost, assigning payment weights, and ended with testing the validity of this new casemix system. Coefficient of variation, reduction in variance, linear regression, and split-half cross-validation were employed. The casemix for sub-acute and non-acute inpatient services contained 98 groups. Two percent of them had a coefficient of variation of the cost of higher than 1.5. The reduction in variance of cost after the classification was 32%. Two classification variables (physical function and the rehabilitation impairment categories) were key determinants of the cost (adjusted R2 = 0.749, p = .001). Validity results of split-half cross-validation of sub-acute and non-acute inpatient service were high. The present study indicated that the casemix for sub-acute and non-acute inpatient services closely predicted the hospital resource use and should be further developed for payment of the inpatients sub-acute and non-acute phase.

Analysis of MRSA-attributed costs of hospitalized patients in Germany.

PubMed

Hübner, C; Hübner, N-O; Hopert, K; Maletzki, S; Flessa, S

2014-10-01

Infections with methicillin-resistant Staphylococcus aureus (MRSA) are assumed to have a high economic impact due to increased hygienic measures and prolonged hospital length of stay. However, surveys on the real expenditure for the prevention and treatment of MRSA are scarce, in particular with regard to the German Diagnosis-Related Groups (G-DRG) payment system. The aim of our study is to empirically assess the additional cost for MRSA management measures and to identify the main cost drivers in the whole process from the hospital's point of view. We conducted a one-year retrospective analysis of MRSA-positive cases in a German university hospital and determined the cost of hygienic measures, laboratory costs, and opportunity costs due to isolation time and extended lengths of stay. A total of 182 cases were included in the analysis. The mean length of hospital stay was 22.75 days and the mean time in isolation was 17.08 days, respectively. Overall, the calculated MRSA-attributable costs were 8,673.04 per case, with opportunity costs making up, by far, the largest share (77.45 %). Our study provides a detailed up-to-date analysis of MRSA-attributed costs in a hospital. It allows a current comparison to previous studies worldwide. Moreover, it offers the prerequisites to investigate the adequate reimbursement of MRSA burden in the DRG payment system and to assess the efficiency of targeted hygienic measures in the prevention of MRSA.

Comparative cost analysis of inpatient integrative medicine-Results of a pilot study.

PubMed

Ostermann, Thomas; Lauche, Romy; Cramer, Holger; Dobos, Gustav

2017-06-01

Costs of integrative treatment alone and in comparison with other treatment approaches have scarcely been reported in the past. This study presents results of a comparative cost analysis of an inpatient integrative medicine treatment costs. Data from 2006 for inpatients referred to a Department of Integrative Medicine in Germany were used. Case-related treatment costs were calculated, and transformed into Casemix-Indices and revenues per DRG. Costs were compared between departments at the same hospital and between different hospitals using univariate statistics and Chi-Square tests. In total 1253 inpatients (81.4% female, 61.1±14.4years) were included in the current analysis. Most patients were treated for diseases of the musculoskeletal system (57.2%), followed by diseases of the digestive system (11.4%), and diseases of the nervous system (10.4%). The department received an additional payment for most of the patients (88.0%), which led to an effective appreciation of 10.8% per case compared to the standardized Casemix-Index. In-house comparisons with other departments found the department in close vicinity to the departments of Internal medicine with regards to CMI and mean revenue, however the Patient Clinical Complexity Level was significantly lower in the Integrative medicine department. The interhospital comparison revealed comparable Casemix-Index and DRG-revenue, however the additional payment increased the mean revenue significantly. Modern integrative in-patient treatment is mostly cost-equivalent to conventional treatment. Cost effectiveness studies should be considered to further investigate the potential of integrative in patient treatment. Copyright © 2016 Elsevier Ltd. All rights reserved.

Impact of a function-based payment model on the financial performance of acute inpatient medical rehabilitation providers: a simulation analysis.

PubMed

Sutton, J P; DeJong, G; Song, H; Wilkerson, D

1997-12-01

To operationalize research findings about a medical rehabilitation classification and payment model by building a prototype of a prospective payment system, and to determine whether this prototype model promotes payment equity. This latter objective is accomplished by identifying whether any facility or payment model characteristics are systematically associated with financial performance. This study was conducted in two phases. In Phase 1 the components of a diagnosis-related group (DRG)-like payment system, including a base rate, function-related group (FRG) weights, and adjusters, were identified and estimated using hospital cost functions. Phase 2 consisted of a simulation analysis in which each facility's financial performance was modeled, based on its 1990-1991 case mix. A multivariate regression equation was conducted to assess the extent to which characteristics of 42 rehabilitation facilities contribute toward determining financial performance under the present Medicare payment system as well as under the hypothetical model developed. Phase 1 (model development) included 61 rehabilitation hospitals. Approximately 59% were rehabilitation units within a general hospital and 48% were teaching facilities. The number of rehabilitation beds averaged 52. Phase 2 of the stimulation analysis included 42 rehabilitation facilities, subscribers to UDS in 1990-1991. Of these, 69% were rehabilitation units and 52% were teaching facilities. The number of rehabilitation beds averaged 48. Financial performance, as measured by the ratio of reimbursement to average costs. Case-mix index is the primary determinant of financial performance under the present Medicare payment system. None of the facility characteristics included in this analysis were associated with financial performance under the hypothetical FRG payment model. The most notable impact of an FRG-based payment model would be to create a stronger link between resource intensity and level of reimbursement, resulting in greater equity in the reimbursement of inpatient medical rehabilitation hospitals.

[DRG systems in Europe. Incentives, purposes and differences in 12 countries].

PubMed

Geissler, A; Scheller-Kreinsen, D; Quentin, W; Busse, R

2012-05-01

DRG systems were introduced across Europe based on expected transparency and efficiency gains. However, European DRG systems have not been systematically analysed so far. As a consequence little is known about the relative strengths and weaknesses of different DRG systems. The EuroDRG project closed this research and knowledge gap by systematically analysing and comparing the DRG systems of 12 countries with different health systems (Austria, the UK, Estonia, Finland, France, Germany, Ireland, The Netherlands, Poland, Portugal, Spain and Sweden).This article summarizes the results of this analysis illustrating how DRG systems across Europe differ with regard to policy goals, patient classification, data collection, price setting and actual reimbursement. Moreover, it outlines which main challenges arise within and across the different types of DRG systems. The results show that the European DRG systems are very heterogeneous. Even if the basic DRG approach of grouping similar patients remains the same across countries, the design of the main building blocks differs to a great extent.

[Quality assessment of dermatology in the G-DRG system 2004].

PubMed

Fürstenberg, T; Hensen, P; Rompel, R; Roeder, N

2004-11-01

Since January 2004, all German hospitals have been obliged to operate with a new hospital funding system based on DRGs. For the DRG system to serve as a fair basis for reimbursement requires that the dermatologic services be adequately covered in the classification system. The German Dermatologic Society (DDG) in cooperation with the DRG-Research Group of the University Hospital Muenster carried out a DRG evaluation study. Based on these results, suggestions for the adjustment of the G-DRG system were proposed by the DDG in the G-DRG adaptation round for 2004. Based on data of the DRG evaluation project (14,555 dermatological cases from 19 hospitals) the homogeneity in the G-DRG system 2004 was examined and compared with the quality of depiction in the G-DRG version 1.0. The correlation between expenditure and case mix index in the hospitals improved in the G-DRG system 2004. Most proposals submitted by the German Dermatologic Society for the adaptation into the G-DRG system 2004 were accepted. Some fundamental problems such as reimbursement of high cost drugs and special services, as well as the reimbursement of high and low outliers, were only marginally addressed. The G-DRG system 2004 will need to be continuously adapted in the field of dermatology. Based on this work, the German Dermatologic Society has made suggestions to be adapted in the G-DRG system 2005 and submitted them to the German DRG Institute.

Reforming reimbursement of public hospitals in Greece during the economic crisis: Implementation of a DRG system.

PubMed

Polyzos, Nikolaos; Karanikas, Haralampos; Thireos, Eleftherios; Kastanioti, Catherine; Kontodimopoulos, Nick

2013-01-01

Until recently, in-patient NHS hospital care in Greece was reimbursed via an anachronistic and under-priced retrospective per diem system, which has been held primarily responsible for continuous budget deficits. The purpose of this paper is to present the efforts of the Ministry of Health (MoH) to implement a new DRG-based payment system. As in many countries, the decision was to adopt a patient classification from abroad and to refine it for use in Greece with national data. Pricing was achieved with a combination of activity-based costing with data from selected Greek hospitals, and "imported" cost weights. Data collection, IT support and monitoring are provided via ESY.net, a web-based facility developed and implemented by the MoH. After an initial pilot testing of the classification in 20 hospitals, complete DRG reimbursement data was reported by 113 hospitals (85% of total) for the fourth quarter of 2011. The recorded monthly increase in patient discharges billed with the new system and in revenue implies increasing adaptability by the hospitals. However, the unfavorable inlier vs. outlier distribution of discharges and revenue observed in some health regions signifies the need for corrective actions. The importance of this reimbursement reform is discussed in light of the current crisis faced by the Greek economy. There is yet much to be done and many projects are currently in progress to support this effort; however the first cost containment results are encouraging. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Access to innovation: is there a difference in the use of expensive anticancer drugs between French hospitals?

PubMed

Bonastre, Julia; Chevalier, Julie; Van der Laan, Chantal; Delibes, Michel; De Pouvourville, Gerard

2014-06-01

In DRG-based hospital payment systems, expensive drugs are often funded separately. In France, specific expensive drugs (including a large proportion of anticancer drugs) are fully reimbursed up to national reimbursement tariffs to ensure equity of access. Our objective was to analyse the use of expensive anticancer drugs in public and private hospitals, and between regions. We had access to sales per anticancer drug and per hospital in the year 2008. We used a multilevel model to study the variation in the mean expenditure of expensive anticancer drugs per course of chemotherapy and per hospital. The mean expenditure per course of chemotherapy was €922 [95% CI: 890-954]. At the hospital level, specialisation in chemotherapies for breast cancers was associated with a higher expenditure of anticancer drugs per course for those hospitals with the highest proportion of cancers at this site. There were no differences in the use of expensive drugs between the private and the public hospital sector after controlling for case mix. There were no differences between the mean expenditures per region. The absence of disparities in the use of expensive anticancer drugs between hospitals and regions may indicate that exempting chemotherapies from DRG-based payments and providing additional reimbursement for these drugs has been successful at ensuring equal access to care. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

20 CFR 30.710 - How are payments for inpatient medical services determined?

Code of Federal Regulations, 2010 CFR

2010-04-01

... services determined? 30.710 Section 30.710 Employees' Benefits OFFICE OF WORKERS' COMPENSATION PROGRAMS... services determined? (a) OWCP will pay for inpatient medical services according to pre-determined... discharges will be classified according to the DRGs prescribed by CMS in the form of the DRG Grouper software...

[Orthopedic and trauma surgery in the German-DRG-System 2009].

PubMed

Franz, D; Windolf, J; Siebert, C H; Roeder, N

2009-01-01

The German DRG-System was advanced into version 2009. For orthopedic and trauma surgery significant changes concerning coding of diagnoses, medical procedures and concerning the DRG-structure were made. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2008 and 2009 based on the publications of the German DRG-institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2009 focussed on the development of DRG-structure, DRG-validation and codes for medical procedures to be used for very complex cases. The outcome of these changes for German hospitals may vary depending in the range of activities. G-DRG-System gained complexity again. High demands are made on correct and complete coding of complex orthopedic and trauma surgery cases. Quality of case-allocation within the G-DRG-System was improved. Nevertheless, further adjustments of the G-DRG-System especially for cases with severe injuries are necessary.

Comparison of the Revenue Situation in Interventional Radiology Based on the Example of Peripheral Artery Disease in the Case of a DRG Payment System and Various Internal Treatment Charges.

PubMed

Vogt, Florian M; Hunold, Peter; Haegele, Julian; Stahlberg, Erik; Barkhausen, Jörg; Goltz, Jan Peter

2018-04-01

 Calculation of process-orientated costs for inpatient endovascular treatment of peripheral artery disease (PAD) from an interventional radiology (IR) perspective. Comparison of revenue situations in consideration of different ways to calculate internal treatment charges (ITCs) and diagnosis-related groups (DRG) for an independent IR department.  Costs (personnel, operating, material, and indirect costs) for endovascular treatment of PAD patients in an inpatient setting were calculated on a full cost basis. These costs were compared to the revenue situation for IR for five different scenarios: 1) IR receives the total DRG amount. IR receives the following DRG shares using ITCs based on InEK shares for 2) "Radiology" cost center type, 3) "OP" cost center type, 4) "Radiology" and "OP" cost center type, and 5) based on DKG-NT (scale of charges of the German Hospital Society).  78 patients (mean age: 68.6 ± 11.4y) with the following DRGs were evaluated: F59A (n = 6), F59B (n = 14), F59C (n = 20) and F59 D (n = 38). The length of stay for these DRG groups was 15.8 ± 12.1, 9.4 ± 7.8, 2.8 ± 3.7 and 3.4 ± 6.5 days Material costs represented the bulk of all costs, especially if new and complex endovascular procedures were performed. Revenues for neither InEK shares nor ITCs based on DKG-NT were high enough to cover material costs. Contribution margins for the five scenarios were 1 = € 1,539.29, 2 = € -1,775.31, 3 = € -2,579.41, 4 = € -963.43, 5 = € -2,687.22 in F59A, 1 = € -792.67, 2 = € -2,685.00, 3 = € -2,600.81, 4 = € -1,618.94, 5 = € -3,060.03 in F59B, 1 = € -879.87, 2 = € -2,633.14, 3 = € -3,001.07, 4 = € -1,952.33, 5 = € -3,136.24 in F59C and 1 = € 703.65, 2 = € -106.35, 3 = € -773.86, 4 = € 205.14, 5 = € -647.22 in F59 D. InEK shares return on average € 150 - 500 more than ITCs based on the DKG-NT catalog.  In this study positive contribution margins were seen only if IR receives the complete DRG amount. InEK shares do not cover incurred costs, with material costs representing the main part of treatment costs. Internal treatment charges based on the DKG-NT catalog provide the worst cost coverage.   · Internal treatment charges based on the DKG-NT catalog provide the worst cost coverage for interventional radiology at our university hospital.. · Shares from the InEK matrix such as the cost center "radiology" or "OP" as revenue for IR are not sufficient to cover incurred costs. A positive contribution margin is achieved only in the case of a compensation method in which IR receives the total DRG amount.. · Vogt FM, Hunold P, Haegele J et al. Comparison of the Revenue Situation in Interventional Radiology Based on the Example of Peripheral Artery Disease in the Case of a DRG Payment System and Various Internal Treatment Charges. Fortschr Röntgenstr 2017; 190: 348 - 357. © Georg Thieme Verlag KG Stuttgart · New York.

DRG coding practice: a nationwide hospital survey in Thailand.

PubMed

Pongpirul, Krit; Walker, Damian G; Rahman, Hafizur; Robinson, Courtland

2011-10-31

Diagnosis Related Group (DRG) payment is preferred by healthcare reform in various countries but its implementation in resource-limited countries has not been fully explored. This study was aimed (1) to compare the characteristics of hospitals in Thailand that were audited with those that were not and (2) to develop a simplified scale to measure hospital coding practice. A questionnaire survey was conducted of 920 hospitals in the Summary and Coding Audit Database (SCAD hospitals, all of which were audited in 2008 because of suspicious reports of possible DRG miscoding); the questionnaire also included 390 non-SCAD hospitals. The questionnaire asked about general demographics of the hospitals, hospital coding structure and process, and also included a set of 63 opinion-oriented items on the current hospital coding practice. Descriptive statistics and exploratory factor analysis (EFA) were used for data analysis. SCAD and Non-SCAD hospitals were different in many aspects, especially the number of medical statisticians, experience of medical statisticians and physicians, as well as number of certified coders. Factor analysis revealed a simplified 3-factor, 20-item model to assess hospital coding practice and classify hospital intention. Hospital providers should not be assumed capable of producing high quality DRG codes, especially in resource-limited settings.

42 CFR 412.208 - Puerto Rico rates for Federal fiscal year 1988.

Code of Federal Regulations, 2010 CFR

2010-10-01

... medical education costs; (3) Adjusting for area variations in hospital wage levels; and (4) Excluding an estimate of the payments for hospitals that serve a disproportionate share of low-income patients. (e... weighting factor determined under § 412.60(b) for that DRG. (i) Adjusting for different area wage levels...

[Orthopedic and trauma surgery in the German DRG system 2008].

PubMed

Franz, D; Kaufmann, M; Siebert, C H; Windolf, J; Roeder, N

2008-04-01

The German DRG (diagnosis-related groups) system has been modified and updated into version 2008. For orthopedic and trauma surgery significant changes concerning coding of diagnoses, medical procedures and the DRG structure were made. The modified version has been analyzed in order to ascertain whether the DRG system is suitably qualified to fulfill the demands of the reimbursement system or whether further improvements are necessary. Analysis of the severity of relevant side-effect diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 was carried out based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2008 focused on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities. G-DRG system has become even more complex and the new regulations have also resulted in new problems associated with complications.. High demands are made on correct and complete coding of complex orthopedic and trauma surgery cases. Quality of case allocation within the G-DRG system has been improved. Nevertheless, further improvements of the G-DRG system are necessary, especially for cases with severe injuries.

[The G-DRG system 2008. Relevant changes for rheumatology].

PubMed

Fiori, W; Lakomek, H-J; Buscham, K; Lehmann, H; Liman, W; Fuchs, A-K; Hülsemann, J L; Roeder, N

2008-05-01

The G-DRG system 2008 once again brings many changes to rheumatological departments in Germany. The following article presents the main general and specific changes in the G-DRG system, as well as in the classification systems for diagnoses and procedures and in invoicing for 2008. Since the G-DRG system is only a tool for the redistribution of resources, every hospital needs to analyze the economic effects of the system by applying the G-DRG transition grouper to its own cases. Depending on their clinical focus, rheumatological departments may experience positive or negative effects from the system's application. The strain placed on hospitals by the inadequate funding of increased costs needs to be assessed separately from the effects of redistribution by the G-DRG system.

Cost Analysis of Integrative Inpatient Treatment Based on DRG Data: The Example of Anthroposophic Medicine

PubMed Central

Heinz, Jürgen; Fiori, Wolfgang; Heusser, Peter

2013-01-01

Background. Much work has been done to evaluate the outcome of integrative inpatient treatment but scarcely the costs. This paper evaluates the costs for inpatient treatment in three anthroposophic hospitals (AHs). Material and Methods. Cost and performance data from a total of 23,180 cases were analyzed and compared to national reference data. Subgroup analysis was performed between the cases with and without anthroposophic medical complex (AMC) treatment. Results. Costs and length of stay in the cases without AMC displayed no relevant differences compared to the national reference data. In contrast the inlier cases with AMC caused an average of € 1,394 more costs. However costs per diem were not higher than those in the national reference data. Hence, the delivery of AMC was associated with a prolonged length of stay. 46.6% of the cases with AMC were high outliers. Only 10.6% of the inlier cases with AMC were discharged before reaching the mean length of stay of each DRG. Discussion. Treatment in an AH is not generally associated with an increased use of resources. However, the provision of AMC leads to a prolonged length of stay and cannot be adequately reimbursed by the current G-DRG system. Due to the heterogeneity of the patient population, an additional payment should be negotiated individually. PMID:23431346

[Monitoring of nursing service context factors: first descriptive results of a cross-sectional Swiss study prior the introduction of SwissDRG].

PubMed

Kleinknecht-Dolf, Michael; Spichiger, Elisabeth; Frei, Irena Anna; Müller, Marianne; Martin, Jacqueline S; Spirig, Rebecca

2015-04-01

The adoption of DRG-based payment systems has narrowed hospitals' financial margins, necessitating streamlining and process optimization. The experience of other countries shows that this restructuring can influence context factors essential to the delivery of nursing care. As a result, nursing care quality and patient safety may be impacted. The Sinergia Project aims to develop a monitoring model and related instruments to continuously monitor the impact of DRG-based reimbursement on central nursing service context factors. The descriptive, quantitative results were collected within the framework of a study with a mixed methods design by means of an online survey in which nurses from five hospitals participated. The results show that the nursing service context factors examined (nursing care complexity, quality of the work environment, management, moral distress and job satisfaction), have relevance in all practice areas as regards practice setting and nursing care delivery. Patterns can be recognized that are consistent with those found in the literature and which could be an indication of the relationships between the context factors above, as was hypothesized in the model. The study has provided the participating hospitals with useful data upon which to base discussions on ensuring quality of nursing care and practice development, in addition to information important to the further development of the model and the instruments employed.

Coding response to a case-mix measurement system based on multiple diagnoses.

PubMed

Preyra, Colin

2004-08-01

To examine the hospital coding response to a payment model using a case-mix measurement system based on multiple diagnoses and the resulting impact on a hospital cost model. Financial, clinical, and supplementary data for all Ontario short stay hospitals from years 1997 to 2002. Disaggregated trends in hospital case-mix growth are examined for five years following the adoption of an inpatient classification system making extensive use of combinations of secondary diagnoses. Hospital case mix is decomposed into base and complexity components. The longitudinal effects of coding variation on a standard hospital payment model are examined in terms of payment accuracy and impact on adjustment factors. Introduction of the refined case-mix system provided incentives for hospitals to increase reporting of secondary diagnoses and resulted in growth in highest complexity cases that were not matched by increased resource use over time. Despite a pronounced coding response on the part of hospitals, the increase in measured complexity and case mix did not reduce the unexplained variation in hospital unit cost nor did it reduce the reliance on the teaching adjustment factor, a potential proxy for case mix. The main implication was changes in the size and distribution of predicted hospital operating costs. Jurisdictions introducing extensive refinements to standard diagnostic related group (DRG)-type payment systems should consider the effects of induced changes to hospital coding practices. Assessing model performance should include analysis of the robustness of classification systems to hospital-level variation in coding practices. Unanticipated coding effects imply that case-mix models hypothesized to perform well ex ante may not meet expectations ex post.

[ENT medicine and head and neck surgery in the G-DRG system 2008].

PubMed

Franz, D; Roeder, N; Hörmann, K; Alberty, J

2008-09-01

Further developments in the German DRG system have been incorporated into the 2008 version. For ENT medicine and head and neck surgery significant changes concerning coding of diagnoses, medical procedures and concerning the DRG-structure were made. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2008 focussed on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities. The G-DRG system has gained in complexity again. High demands are made on correct and complete coding of complex ENT and head and neck surgery cases. Quality of case allocation within the G-DRG system has been improved. For standard cases quality of case allocation is adequate. Nevertheless, further adjustments of the G-DRG system especially for cases with complex neck surgery are necessary.

How access to long-term care affects home health transfers.

PubMed

Kenney, G M

1993-01-01

This study examines the determinants of home health use after hospitalization for acute illness for eleven diagnosis-related groups (DRGs) in 1985, drawing on data from four primary sources: Medicare hospital bills, Medicare home health bills, the Medicare and Medicaid Automated Certification System files, and the American Hospital Association Survey. Separate Tobit models are estimated for each DRG. The analysis shows that transfers to home health care are heavily influenced by the hospital's long-term care arrangement and by conditions in local nursing home and home health care markets. Especially important is whether a hospital has its own long-term care unit, swing beds, or both, and whether nursing home beds are available in the local area. Patients discharged from hospitals are more likely to use home health care in areas with a low supply of nursing home beds and low Medicaid reimbursement levels for skilled nursing facilities. The results of this study have implications for proposals to extend Medicare's Prospective Payment System for hospital services to include postacute care. Proponents of a "bundled payment" that encompasses both acute and postacute services argue that the current system leads to inefficiencies and inequities. This analysis points to systematic relationships between home health and nursing home services, which should be factored into the development of a bundled payment policy.

[Heterogeneity of costs and performance for penetrating eye injuries and suturing amniotic membranes under DRG conditions : Analysis of case constellations of the G-DRG C01B of the Regensburg University eye clinic].

PubMed

Franz, D; Mrosek, M; Mrosek, S; Helbig, H; Framme, C

2012-01-01

Patients with penetrating eye injuries are a very heterogeneous group both medically and economically. Since 2009, treatment involving sutures for open eye injuries and cases requiring amniotic membrane transplantation (AMT) were allocated to DRG C01B of the German diagnosis-related group system. However, given the significant clinical differences between these treatments, an inhomogeneity of costs to performance is postulated. This analysis describes case allocation problems within the G-DRG C01B category and presents solutions. A retrospective analysis was conducted from the standardized G-DRG data of 277 patients with open eye injuries and AMT between 2007 and 2008, grouped under the 2008 G-DRG system version to the G-DRG C01Z category. This data was provided by the Department of Ophthalmology at the University Hospital Regensburg. Additionally case-based data of the following were supplemented: length of surgery, time of anesthesia and intensity of patient care. Fixed and variable costs were determined for surgery and other inpatient treatment. Finally, an analysis of the heterogeneity of costs within the G-DRG C01B of the G-DRG system 2009 was implemented. Inhomogeneity was evident within the G-DRG C01B of the G-DRG system 2009 for the two groups suture of open eye injuries and AMT concerning the parameters length of stay, proportion of high outliers and cost per case. Multiple surgeries during an inpatient stay lead to an extended length of stay and increasing costs, especially within the AMT group. Intensity of patient care and the consideration of patient comorbidity did not yield relevant differences. The quality of the G-DRG system is measured by its ability to obtain adequate funding for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation for patients with open eye injuries within the G-DRG C01B of the German DRG system 2009. As a result of the present study, cases with amniotic membrane transplantation should not be allocated to the G-DRG C01B. A petition has been presented by the German Association of Ophthalmology (DOG) to the German DRG Institute to restructure the G-DRG C01B. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process.

42 CFR 412.10 - Changes in the DRG classification system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Changes in the DRG classification system. 412.10... § 412.10 Changes in the DRG classification system. (a) General rule. CMS issues changes in the DRG classification system in a Federal Register notice at least annually. Except as specified in paragraphs (c) and...

42 CFR 412.10 - Changes in the DRG classification system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Changes in the DRG classification system. 412.10... § 412.10 Changes in the DRG classification system. (a) General rule. CMS issues changes in the DRG classification system in a Federal Register notice at least annually. Except as specified in paragraphs (c) and...

[ENT and head and neck surgery in the German DRG system 2007].

PubMed

Franz, D; Roeder, N; Hörmann, K; Alberty, J

2007-07-01

The German DRG system has been further developed into version 2007. For ENT and head and neck surgery, significant changes in the coding of diagnoses and medical operations as well as in the the DRG structure have been made. New ICD codes for sleep apnoea and acquired tracheal stenosis have been implemented. Surgery on the acoustic meatus, removal of auricle hyaline cartilage for transplantation (e. g. rhinosurgery) and tonsillotomy have been coded in the 2007 version. In addition, the DRG structure has been improved. Case allocation of more than one significant operation has been established. The G-DRG system has gained in complexity. High demands are made on the coding of complex cases, whereas standard cases require mostly only one specific diagnosis and one specific OPS code. The quality of case allocation for ENT patients within the G-DRG system has been improved. Nevertheless, further adjustments of the G-DRG system are necessary.

[Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?].

PubMed

Mahlke, L; Lefering, R; Siebert, H; Windolf, J; Roeder, N; Franz, D

2013-11-01

Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system. A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out. The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system. Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.

[What is the value of pain therapy in the German refined diagnosis-related-groups system?].

PubMed

Meissner, W; Thoma, R; Bauer, M

2006-03-01

The German refined diagnosis-related-groups (G-DRG) system was introduced on 1st January 2003, initially on a voluntary basis and on 1st January 2004 the use of a G-DRG costing for stationary hospital treatment became obligatory. The possibility of a description of acute and chronic pain therapy in the G-DRG system was initially rudimentary and not logically planned and also a fair allotment of proceeds according to resources was not possible. By further development of the G-DRG system, pain therapeutic treatment could be improved in some areas, but in others it still remains unsatisfactory. This article offers a summary of the underlying systematics of the G-DRG system and consideration of chronic and current pain therapy in the G-DRG system 2006. In addition to information on currently available possibilities of a pain therapeutical coding in conformation with the G-DRG system, the tasks which are still outstanding will be outlined.

DRG coding practice: a nationwide hospital survey in Thailand

PubMed Central

2011-01-01

Background Diagnosis Related Group (DRG) payment is preferred by healthcare reform in various countries but its implementation in resource-limited countries has not been fully explored. Objectives This study was aimed (1) to compare the characteristics of hospitals in Thailand that were audited with those that were not and (2) to develop a simplified scale to measure hospital coding practice. Methods A questionnaire survey was conducted of 920 hospitals in the Summary and Coding Audit Database (SCAD hospitals, all of which were audited in 2008 because of suspicious reports of possible DRG miscoding); the questionnaire also included 390 non-SCAD hospitals. The questionnaire asked about general demographics of the hospitals, hospital coding structure and process, and also included a set of 63 opinion-oriented items on the current hospital coding practice. Descriptive statistics and exploratory factor analysis (EFA) were used for data analysis. Results SCAD and Non-SCAD hospitals were different in many aspects, especially the number of medical statisticians, experience of medical statisticians and physicians, as well as number of certified coders. Factor analysis revealed a simplified 3-factor, 20-item model to assess hospital coding practice and classify hospital intention. Conclusion Hospital providers should not be assumed capable of producing high quality DRG codes, especially in resource-limited settings. PMID:22040256

[Hand surgery in the German DRG System 2007].

PubMed

Franz, D; Windolf, J; Kaufmann, M; Siebert, C H; Roeder, N

2007-05-01

Hand surgery often needs only a short length of stay in hospital. Patients' comorbidity is low. Many hand surgery procedures do not need inpatient structures. Up until 2006 special procedures of hand surgery could not be coded. The DRG structure did not separate very complex and less complex operations. Specialized hospitals needed a proper case allocation of their patients within the G-DRG system. The DRG structure concerning hand surgery increased in version 2007 of the G-DRG system. The main parameter of DRG splitting is the complexity of the operation. Furthermore additional criteria such as more than one significant OR procedure, the patients' age, or special diagnoses influence case allocation. A special OPS code for complex cases treated with hand surgery was implemented. The changes in the DRG structure and the implementation of the new OPS code for complex cases establish a strong basis for the identification of different patient costs. Different case allocation leads to different economic impacts on departments of hand surgery. Whether the new OPS code becomes a DRG splitting parameter has to be calculated by the German DRG Institute for further DRG versions.

[Adjustment of the German DRG system in 2009].

PubMed

Wenke, A; Franz, D; Pühse, G; Volkmer, B; Roeder, N

2009-07-01

The 2009 version of the German DRG system brought significant changes for urology concerning coding of diagnoses, medical procedures and the DRG structure. In view of the political situation and considerable economic pressure, a critical analysis of the 2009 German DRG system is warranted. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2008 and 2009 based on the publications of the German DRG-institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). The relevant diagnoses, medical procedures and German DRGs in the versions 2008 and 2009 were analysed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2009 focus on the development of the DRG structure, DRG validation and codes for medical procedures to be used for very complex cases. The outcome of these changes for German hospitals may vary depending in the range of activities. The German DRG system again gained complexity. High demands are made on correct and complete coding of complex urology cases. The quality of case allocation in the German DRG system was improved. On the one hand some of the old problems (e.g. enterostomata) still persist, while on the other hand new problems evolved out of the attempt to improve the case allocation of highly complex and expensive cases. Time will tell whether the increase in highly specialized DRG with low case numbers will continue to endure and reach acceptable rates of annual fluctuations.

[Is polytrauma affordable these days? G-DRG system vs per diem charge based on 1,030 patients with multiple injuries].

PubMed

Qvick, B; Buehren, V; Woltmann, A

2012-10-01

The introduction of diagnosis-related groups (DRG) in Germany comprises the risk of a non-cost-effective reimbursement in complex medical treatments. The aim of this study was to compare the reimbursement between the DRG system and the system of hospital per diem charge in effect until now. The G-DRG (Version 2004) reimbursement was calculated for 1,030 polytrauma patients (average ISS 26.4) treated at the BGU Murnau from 2000 to 2004, using a base value of 2900 euros, and compared to the reimbursement of hospital per diem charge. Just half of all polytrauma patients are classified as a polytrauma according to the DRG (18.7%) or as requiring artificial respiration based on the DRG (29.1%). The average G-DRG reimbursement was 27,157 euros vs 36,387 euros (74.6%). Patients with minor trauma, increasing age, high GCS, ICU stay without artificial respiration, trauma of the upper extremity and patients who survived show the greatest discrepancy. A revision of the G-DRG definition of polytrauma is necessary to ensure adequate reimbursement for management of patients with multiple injuries. The severity of a trauma has to be considered in the DRG system.

Coding Response to a Case-Mix Measurement System Based on Multiple Diagnoses

PubMed Central

Preyra, Colin

2004-01-01

Objective To examine the hospital coding response to a payment model using a case-mix measurement system based on multiple diagnoses and the resulting impact on a hospital cost model. Data Sources Financial, clinical, and supplementary data for all Ontario short stay hospitals from years 1997 to 2002. Study Design Disaggregated trends in hospital case-mix growth are examined for five years following the adoption of an inpatient classification system making extensive use of combinations of secondary diagnoses. Hospital case mix is decomposed into base and complexity components. The longitudinal effects of coding variation on a standard hospital payment model are examined in terms of payment accuracy and impact on adjustment factors. Principal Findings Introduction of the refined case-mix system provided incentives for hospitals to increase reporting of secondary diagnoses and resulted in growth in highest complexity cases that were not matched by increased resource use over time. Despite a pronounced coding response on the part of hospitals, the increase in measured complexity and case mix did not reduce the unexplained variation in hospital unit cost nor did it reduce the reliance on the teaching adjustment factor, a potential proxy for case mix. The main implication was changes in the size and distribution of predicted hospital operating costs. Conclusions Jurisdictions introducing extensive refinements to standard diagnostic related group (DRG)-type payment systems should consider the effects of induced changes to hospital coding practices. Assessing model performance should include analysis of the robustness of classification systems to hospital-level variation in coding practices. Unanticipated coding effects imply that case-mix models hypothesized to perform well ex ante may not meet expectations ex post. PMID:15230940

Cost of practice in a tertiary/quaternary referral center: is it sustainable?

PubMed

Cologne, K G; Hwang, G S; Senagore, A J

2014-11-01

Third-party payers are moving toward a bundled care payment system. This means that there will need to be a warranty cost of care-where the cost of complexity and complication rates is built into the bundled payment. The theoretical benefit of this system is that providers with lower complication rates will be able to provide care with lower warranty costs and lower overall costs. This may also result in referring riskier patients to tertiary or quaternary referral centers. Unless the payment model truly covers the higher cost of managing such referred cases, the economic risk may be unsustainable for these centers. We took the last seven patients that were referred by other surgeons as "too high risk" for colectomy at other centers. A contribution margin was calculated using standard Medicare reimbursement rates at our institution and cost of care based on our administrative database. We then recalculated a contribution margin assuming a 3 % reduction in payment for a higher than average readmission rate, like that which will take effect in 2014. Finally, we took into account the cost of any readmissions. Seven patients with diagnosis related group (DRG) 330 were reviewed with an average age of 66.8 ± 16 years, American Society of Anesthesiologists score 2.3 ± 1.0, body mass index 31.6 ± 9.8 kg/m(2) (range 22-51 kg/m(2)). There was a 57 % readmission rate, 29 % reoperation rate, 10.8 ± 7.7 day average initial length of stay with 14 ± 8.6 day average readmission length of stay. Forty-two percent were discharged to a location other than home. Seventy-one percent of these patients had Medicare insurance. The case mix index was 2.45. Average reimbursement for DRG 330 was $17,084 (based on Medicare data) for our facility in 2012, with the national average being $12,520. The total contribution margin among all cases collectively was -$19,122 ± 13,285 (average per patient -$2,731, range -$21,905-$12,029). Assuming a 3 % reimbursement reduction made the overall contribution margin -$22,122 ± 13,285 (average -$3,244). Including the cost of readmission in the variable cost made the contribution margin -$115,741 ± 16,023 (average -$16,534). Care of high-risk patients at tertiary and quaternary referral centers is a very expensive proposition and can lead to financial ruin under the current reimbursement system.

[The challenge of adequate reimbursement for the seriously injured patient in the German DRG system].

PubMed

Franz, D; Lefering, R; Siebert, H; Windolf, J; Roeder, N; Mahlke, L

2013-02-01

Critically injured patients are a very heterogeneous group, medically and economically. Their treatment is a major challenge for both the medical care and the appropriate financial reimbursement. Systematic underfunding can have a significant impact on the quality of patient care. In 2009 the German Trauma Society and the DRG-Research Group of the University Hospital Muenster initialised a DRG evaluation project to analyse the validity of case allocation of critically injured patients within the German DRG system versions 2008 and 2011 with additional consideration of clinical data from the trauma registry of the German Trauma Society. Severe deficits within the G-DRG structure were identified and specific solutions were designed and realised. A retrospective analysis was undertaken of standardised G-DRG data (§ 21 KHEntgG) including case-related cost data from 3 362 critically injured patients in the periods 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals. For 1 241 cases of the sample, complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of critically injured patients within the G-DRG system. Analyses of coding and grouping, performance of case allocation, and the homogeneity of costs in the G-DRG versions 2008 and 2011 were done. The following situations were found: (i) systematic underfunding of trauma patients in the G-DRG-Version 2008, especially trauma patients with acute paraplegia; (ii) participation in the official G-DRG development for 2011 with 13 proposals which were largely realised; (ii) the majority of cases with cost-covering in the G-DRG version 2011; (iv) significant improvements in the quality of statistical criteria; (v) overfunded trauma patients with high intensive care costs; (vi) underfunding for clinically relevant critically injured patients not identified in the G-DRG system. The quality of the G-DRG system is measured by the ability to obtain adequate case allocations for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation of critically injured patients. Additional consideration of the ISS clinical data must be further evaluated. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process. © Georg Thieme Verlag KG Stuttgart · New York.

Monitoring the impact of the DRG payment system on nursing service context factors in Swiss acute care hospitals: Study protocol.

PubMed

Spirig, Rebecca; Spichiger, Elisabeth; Martin, Jacqueline S; Frei, Irena Anna; Müller, Marianne; Kleinknecht, Michael

2014-01-01

With this study protocol, a research program is introduced. Its overall aim is to prepare the instruments and to conduct the first monitoring of nursing service context factors at three university and two cantonal hospitals in Switzerland prior to the introduction of the reimbursement system based on Diagnosis Related Groups (DRG) and to further develop a theoretical model as well as a methodology for future monitoring following the introduction of DRGs. DRG was introduced to all acute care hospitals in Switzerland in 2012. In other countries, DRG introduction led to rationing and subsequently to a reduction in nursing care. As result, nursing-sensitive patient outcomes were seriously jeopardised. Switzerland has the opportunity to learn from the consequences experienced by other countries when they introduced DRGs. Their experiences highlight that DRGs influence nursing service context factors such as complexity of nursing care or leadership, which in turn influence nursing-sensitive patient outcomes. For this reason, the monitoring of nursing service context factors needs to be an integral part of the introduction of DRGs. However, most acute care hospitals in Switzerland do not monitor nursing service context data. Nursing managers and hospital executive boards will be in need of this data in the future, in order to distribute resources effectively. A mixed methods design in the form of a sequential explanatory strategy was chosen. During the preparation phase, starting in spring 2011, instruments were selected and prepared, and the access to patient and nursing data in the hospitals was organized. Following this, online collection of quantitative data was conducted in fall 2011. In summer 2012, qualitative data was gathered using focus group interviews, which helped to describe the processes in more detail. During 2013 and 2014, an integration process is being conducted involving complementing, comparing and contrasting quantitative and qualitative findings. The research program will produce baseline data on nursing service context factors in Swiss acute care hospitals prior to DRG introduction as well as a theoretical model and a methodology to support nursing managers and hospital executive boards in distributing resources effectively. The study was approved by the ethics committees of Basel, Bern, Solothurn and Zürich.

Monitoring the impact of the DRG payment system on nursing service context factors in Swiss acute care hospitals: Study protocol

PubMed Central

Spirig, Rebecca; Spichiger, Elisabeth; Martin, Jacqueline S.; Frei, Irena Anna; Müller, Marianne; Kleinknecht, Michael

2014-01-01

Aims: With this study protocol, a research program is introduced. Its overall aim is to prepare the instruments and to conduct the first monitoring of nursing service context factors at three university and two cantonal hospitals in Switzerland prior to the introduction of the reimbursement system based on Diagnosis Related Groups (DRG) and to further develop a theoretical model as well as a methodology for future monitoring following the introduction of DRGs. Background: DRG was introduced to all acute care hospitals in Switzerland in 2012. In other countries, DRG introduction led to rationing and subsequently to a reduction in nursing care. As result, nursing-sensitive patient outcomes were seriously jeopardised. Switzerland has the opportunity to learn from the consequences experienced by other countries when they introduced DRGs. Their experiences highlight that DRGs influence nursing service context factors such as complexity of nursing care or leadership, which in turn influence nursing-sensitive patient outcomes. For this reason, the monitoring of nursing service context factors needs to be an integral part of the introduction of DRGs. However, most acute care hospitals in Switzerland do not monitor nursing service context data. Nursing managers and hospital executive boards will be in need of this data in the future, in order to distribute resources effectively. Methods/Design: A mixed methods design in the form of a sequential explanatory strategy was chosen. During the preparation phase, starting in spring 2011, instruments were selected and prepared, and the access to patient and nursing data in the hospitals was organized. Following this, online collection of quantitative data was conducted in fall 2011. In summer 2012, qualitative data was gathered using focus group interviews, which helped to describe the processes in more detail. During 2013 and 2014, an integration process is being conducted involving complementing, comparing and contrasting quantitative and qualitative findings. Conclusion: The research program will produce baseline data on nursing service context factors in Swiss acute care hospitals prior to DRG introduction as well as a theoretical model and a methodology to support nursing managers and hospital executive boards in distributing resources effectively. The study was approved by the ethics committees of Basel, Bern, Solothurn and Zürich. PMID:24696673

Heterogeneity of European DRG systems and potentials for a common EuroDRG system

PubMed Central

Geissler, Alexander; Quentin, Wilm; Busse, Reinhard

2015-01-01

Diagnosis-Related Group (DRG) systems across Europe are very heterogeneous, in particular because of different classification variables and algorithms as well as costing methodologies. But, given the challenge of increasing patient mobility within Europe, health systems are forced to incorporate a common patient classification language in order to compare and identify similar patients e.g. for reimbursement purposes. Beside the national adoption of DRGs for a wide range of purposes (measuring hospital activity vs. paying hospitals), a common DRG system can serve as an international communication basis among health administrators and can reduce the national development efforts as it is demonstrated by the NordDRG consortium. PMID:25905484

[G-DRG system 2009: relevant changes for rheumatology].

PubMed

Fiori, W; Liedtke-Dyong, A; Lakomek, H-J; Buscham, K; Lehmann, H; Liman, W; Fuchs, A-K; Bessler, F; Roeder, N

2009-08-01

The following article presents the main general and specific changes in the G-DRG (German diagnosis-related groups) system in terms of the classification systems for diagnoses and procedures as well as the billing process for 2009. Of fundamental relevance is the national weighting of the G-DRG I97Z (complex rheumatologic treatment), which up to now had to be negotiated individually by each hospital. Emphasis is also put on case auditing by the health insurers. Being primarily a tool for redistribution of resources, every hospital has to analyze the economic effects of the 2009 G-DRG system by applying the G-DRG transition grouper to its own cases. Depending on their clinical focus rheumatological departments may experience positive or negative consequences from the development. The strain imposed on hospitals by inadequate refunding of rising costs has to be assessed separately from the effects of redistribution by the G-DRG system.

Case Mix Management Systems: An Opportunity to Integrate Medical Records and Financial Management System Data Bases

PubMed Central

Rusnak, James E.

1987-01-01

Due to previous systems selections, many hospitals (health care facilities) are faced with the problem of fragmented data bases containing clinical, demographic and financial information. Projects to select and implement a Case Mix Management System (CMMS) provide an opportunity to reduce the number of separate physical files and to migrate towards systems with an integrated data base. The number of CMMS candidate systems is often restricted due to data base and system interface issues. The hospital must insure the CMMS project provides a means to implement an integrated on-line hospital information data base for use by departments in operating under a DRG-based Prospective Payment System. This paper presents guidelines for use in selecting a Case Mix Mangement System to meet the hospital's financial and operations planning, budgeting, marketing, and other management needs, while considering the data base implications of the implementation.

[Orthopedic and trauma surgery in the German DRG system. Recent developments].

PubMed

Franz, D; Schemmann, F; Selter, D D; Wirtz, D C; Roeder, N; Siebert, H; Mahlke, L

2012-07-01

Orthopedics and trauma surgery are subject to continuous medical advancement. The correct and performance-based case allocation by German diagnosis-related groups (G-DRG) is a major challenge. This article analyzes and assesses current developments in orthopedics and trauma surgery in the areas of coding of diagnoses and medical procedures and the development of the 2012 G-DRG system. The relevant diagnoses, medical procedures and G-DRGs in the versions 2011 and 2012 were analyzed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes were made for the International Classification of Diseases (ICD) coding of complex cases with medical complications, the procedure coding for spinal surgery and for hand and foot surgery. The G-DRG structures were modified for endoprosthetic surgery on ankle, shoulder and elbow joints. The definition of modular structured endoprostheses was clarified. The G-DRG system for orthopedic and trauma surgery appears to be largely consolidated. The current phase of the evolution of the G-DRG system is primarily aimed at developing most exact descriptions and definitions of the content and mutual delimitation of operation and procedures coding (OPS). This is an essential prerequisite for a correct and performance-based case allocation in the G-DRG system.

[The German DRG system and its effect on imaging quality in ENT, and head and neck surgery].

PubMed

Franz, D; Roeder, N; Hörmann, K; Alberty, J

2006-04-01

The new G-DRG system for 2006 was published in September 2005. This article presents, analyses, and comments essential changes in the G-DRG system for 2006 and their consequences for ENT-Medicine. The complexity of the G-DRG system has increased significantly. In 2006, the case allocation will be more differentiated for common surgical procedures on the middle ear, nose, paranasal sinuses, salivary glands, and for head and neck cancer. Furthermore, the patient's age and the clinical and complexity level (PCCL) will be of increased relevance in selected case constellations. However, diagnostic endoscopies with rigid instruments will still not be regarded as OR procedures. Essential adjustments proposed by the German Association for ENT Medicine (DGHNOKHC) and the ENT Medical Professional Association (HNO-Berufsverband) have been made, and the quality of case allocation of ENT-patients within the G-DRG system improved. Nevertheless, further adjustments to the G-DRG system are necessary.

[Increasingly appropriate depiction of rheumatology for G-DRG reimbursement 2006].

PubMed

Lakomek, H J; Fiori, W; Buscham, K; Hülsemann, J; Köneke, N; Liman, W; Märker-Hermann, E; Roeder, N

2006-02-01

Starting with the second year of the so called "convergence period", specialized rheumatological treatment is now represented by a specific DRG (197Z) in the German G-DRG system. The definition of this DRG is based on the procedure codes for the complex and multimodal treatment of rheumatological inpatients (OPS 8-983 and 8-986). This will result in a more appropriate reimbursement of rheumatological treatment. The implementation of specialized rheumatological treatment can be regarded as exemplary for the incorporation of medical specializations into DRG systems. The first step is the definition of the characteristics by procedure codes, which can consequently be utilized within the grouping algorithm. After an inadequate representation of a medical specialization within the DRG system has been demonstrated, a new DRG will be established. As no cost data were available, the calculation of a cost weight for the new G-DRG 197Z is not yet possible for 2006. Hence, reimbursement has to be negotiated between the individual hospital and the budget commission of the health insurers. In this context, the use of clinical pathways is considered helpful.

Risk adjustment policy options for casemix funding: international lessons in financing reform.

PubMed

Antioch, Kathryn M; Ellis, Randall P; Gillett, Steve; Borovnicar, Daniel; Marshall, Ric P

2007-09-01

This paper explores modified hospital casemix payment formulae that would refine the diagnosis-related group (DRG) system in Victoria, Australia, which already makes adjustments for teaching, severity and demographics. We estimate alternative casemix funding methods using multiple regressions for individual hospital episodes from 2001 to 2003 on 70 high-deficit DRGs, focussing on teaching hospitals where the largest deficits have occurred. Our casemix variables are diagnosis- and procedure-based severity markers, counts of diagnoses and procedures, disease types, complexity, day outliers, emergency admission and "transfers in." The results are presented for four policy options that vary according to whether all of the dollars or only some are reallocated, whether all or some hospitals are used and whether the alternatives augment or replace existing payments. While our approach identifies variables that help explain patient cost variations, hospital-level simulations suggest that the approaches explored would only reduce teaching hospital underpayment by about 10%. The implications of various policy options are discussed.

The effect of competition on the relationship between the introduction of the DRG system and quality of care in Korea.

PubMed

Kim, Seung Ju; Park, Eun-Cheol; Kim, Sun Jung; Han, Kyu-Tae; Han, Euna; Jang, Sung-In; Kim, Tae Hyun

2016-02-01

The diagnosis-related group-based prospective payment programme was introduced in Korea in 1997 as a pilot programme to control health spending. In July 2013, the programme was implemented throughout the nation. The aim of our study is to evaluate the relationship between quality of care and market competition following the introduction of the new payment system in Korea. We conduct an observational analysis using National Health Insurance claim data from 2011 to 2014. We analyse data on readmission within 30 days, length of stay, and number of outpatient visits for 1742 hospitals and 821 912 cases. We use a generalized estimating equation model to evaluate readmission within 30 days and number of outpatient visits and a multi-level regression model to assess length of stay. Total readmission within 30 days is 10 727 (1.3%). High competition areas present a lower risk of readmission [odds ratio (OR): 0.95, P: 0.0277], a longer length of stay (1%, P < 0.0001), and an increased number of outpatient visits (Relative Risk: 1.11, P: 0.0011) as compared with moderate competition areas. Risk of readmission is higher in low competition areas as compared with moderate competition areas (OR: 1.21, P < 0.0001). The effects of the introduction of the new payment system differed by degree of market competition. Thus, evaluation about the effect of new payment system on hospital performance should be measured in combination with the degree of hospital market structure. © The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

[The G-DRG System 2009--relevant changes for rheumatology].

PubMed

Fiori, W; Liedtke-Dyong, A; Lakomek, H-J; Buscham, K; Lehmann, H; Liman, W; Fuchs, A-K; Bessler, F; Roeder, N

2010-05-01

The following article presents the major general and specific changes in the G-DRG system, in the classification systems for diagnoses and procedures as well as for the billing process for 2010. Since the G-DRG system is primarily a tool for the redistribution of resources, every hospital needs to analyze the economic effects of the changes by applying the G-DRG transition-grouper to its own cases. Depending on their clinical focus, rheumatological departments may experience positive or negative consequences from the adjustments. In addition, relevant current case law is considered.

Effects of male and female sex steroids on the development of normal and the transient Froriep's dorsal root ganglia of the chick embryo.

PubMed

Liu, Jiali; Chen, Dawei; Goldstein, Ronald S; Cui, Sheng

2005-03-22

Sex steroids can influence developmental processes and support the survival of neurons in the embryonic central nervous system. Recent studies have shown that estrogen receptors are also expressed in the peripheral nervous system, in the dorsal root ganglia (DRG) of chick embryos. However, no studies have examined the effects of sex steroids on development of embryonic DRG. In the present study, 0.2 microg, 1.0 microg, 5.0 microg 10 microg, 20 microg, 25 microg, and 40 microg doses of testosterone or estradiol were delivered to chick embryos at Hamburger and Hamilton stage 18 (E3). The actions of these doses of sex steroids on the development of the C5DRG (fifth cervical ganglion, a "normal" DRG) and C2DRG (a transient ganglion known as a "Froriep's DRG") were then evaluated by quantifying ganglionic volumes, cell number, proliferation, and apoptosis after 1 day of growth to stage 23. We found that both testosterone and estradiol promoted proliferation of cells in both normal DRG and the Froriep's ganglia. By contrast, estradiol significantly increased the number of apoptotic cells, while testosterone strongly inhibited apoptosis. These actions of sex steroids on DRG development were dose-dependent, and C5DRG and C2DRG showed different sensitivities to the applied sex steroids. In addition, the present results demonstrated that specific ER and AR inhibitors (tamoxifen and flutamide) did not influence the effects of 5 microg E2 and 5 microg T on C2 and C5DRG significantly. These results demonstrate that male and female sex steroids can modulate DRG development through an epigenetic mechanism, as had been shown for the central nervous system.

[Orthopedic and trauma surgery in the German DRG System 2007].

PubMed

Franz, D; Kaufmann, M; Siebert, C H; Windolf, J; Roeder, N

2007-03-01

The German Diagnosis-Related Groups (DRG) System was further developed into its 2007 version. For orthopedic and trauma surgery, significant changes were made in terms of the coding of diagnoses and medical procedures, as well as in the DRG structure itself. The German Societies for Trauma Surgery and for Orthopedics and Orthopedic Surgery (Deutsch Gesellschaft für Unfallchirurgie, DGU; and Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, DGOOC) once again cooperated constructively with the German DRG Institute InEK. Among other innovations, new International Classification of Diseases (ICD) codes for second-degree burns were implemented. Procedure codes for joint operations, endoprosthetic-surgery and spine surgery were restructured. Furthermore, a specific code for septic surgery was introduced in 2007. In addition, the DRG structure was improved. Case allocation of patients with more than one significant operation was established. Further DRG subdivisions were established according to the patients age and the Patient Clinical Complexity Level (PCCL). DRG developments for 2007 have improved appropriate case allocation, but once again increased the system's complexity. Clinicians need an ever growing amount of specific coding know-how. Still, further adjustments to the German DRG system are required to allow for a correct allocation of cases and funds.

Financial impact of improved pressure ulcer staging in the acute hospital with use of a new tool, the NE1 Wound Assessment Tool.

PubMed

Young, Daniel L; Shen, Jay J; Estocado, Nancy; Landers, Merrill R

2012-04-01

The NE1 Wound Assessment Tool (NE1 WAT; Medline Industries, Inc, Mundelein, Illinois), previously called the N.E. One Can Stage, was shown to significantly improve accuracy of pressure ulcer (PrU) staging. Improved PrU staging has many potential benefits, including improved care for the patient and better reimbursement. Medicare has incentivized good care and accurate identification of PrUs in the acute care hospital through an additional payment, the Medicare Severity-Diagnosis Related Group (MS-DRG). This article examines the financial impact of NE1 WAT use on the acute care hospital relative to MS-DRG reimbursement. PrU staging accuracy with and without use of the NE1 WAT from previous data was compared with acute care hospital PrU rates obtained from the 2006 National Inpatient Sample. Hill-Rom International Pressure Ulcer Prevalence Survey data were used to estimate the number of MS-DRG-eligible PrUs. There are between 390,000 and 130,000 MS-DRG-eligible PrUs annually. Given current PrU staging accuracy, approximately $209 million in MS-DRG money is being collected. With the improved staging afforded by the NE1 WAT, this figure is approximately $763.9 million. Subtracting the 2 reveals $554.9 million in additional reimbursement that could be generated by using the NE1 WAT. There is a tremendous financial incentive to improve PrU staging. The NE1 WAT has been shown to improve PrU staging accuracy significantly. This improvement has the potential to improve the financial health of acute care hospitals caring for patients with PrUs.

Heterogeneity of European DRG systems and potentials for a common EuroDRG system Comment on "Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries".

PubMed

Geissler, Alexander; Quentin, Wilm; Busse, Reinhard

2015-03-05

Diagnosis-Related Group (DRG) systems across Europe are very heterogeneous, in particular because of different classification variables and algorithms as well as costing methodologies. But, given the challenge of increasing patient mobility within Europe, health systems are forced to incorporate a common patient classification language in order to compare and identify similar patients e.g. for reimbursement purposes. Beside the national adoption of DRGs for a wide range of purposes (measuring hospital activity vs. paying hospitals), a common DRG system can serve as an international communication basis among health administrators and can reduce the national development efforts as it is demonstrated by the NordDRG consortium. © 2015 by Kerman University of Medical Sciences.

Variation in Resource Utilization for Patients With Hip and Pelvic Fractures Despite Equal Medicare Reimbursement.

PubMed

Samuel, Andre M; Webb, Matthew L; Lukasiewicz, Adam M; Basques, Bryce A; Bohl, Daniel D; Varthi, Arya G; Lane, Joseph M; Grauer, Jonathan N

2016-06-01

Medicare currently reimburses hospitals for inpatient admissions with "bundled" payments based on patient Diagnosis-related Groups (DRGs) regardless of true hospital costs. At present, DRG 536 (fractures of the hip and pelvis) includes a broad spectrum of patients with orthopaedic trauma, likely with varying inpatient resource utilization. With the growing incidence of fractures in the elderly, inadequate reimbursements from Medicare for certain patients with DRG 536 may lead to growing financial strain on healthcare institutions caring for these patients with higher costs. The purposes of the study were to determine whether (1) inpatient length of stay; (2) intensive care unit stay; and (3) ventilator time differ among subpopulations with Medicare DRG 536. A total of 56,683 patients, 65 years or older, with fractures of the hip or pelvis were identified in the 2011 and 2012 National Trauma Data Bank. This clinical registry contains data on trauma cases from more than 900 participating trauma centers, allowing analysis of resource utilization in centers across the United States. Patients were grouped in the following subgroups: hip fractures (n = 35,119), nonoperative pelvic fractures (n = 15,506), acetabulum fractures, operative and nonoperative, (n = 7670), and operative pelvic fractures (n = 682). Total inpatient length of stay, intensive care unit (ICU) stay, and ventilator time were compared across groups using multivariate analysis that controlled for hospital factors. After controlling for patient and hospital factors, difference in inpatient length of stay was -0.2 days for patients with nonoperative pelvis fractures compared with inpatient length of stay for patients with hip fractures (95% CI, -0.4 to -0.1 days; p = 0.001); 1.7 days for patient with acetabulum fractures (95% CI, 1.4-1.9 days; p < 0.001); and 7.7 days for patients with operative pelvic fractures (95% CI, 7.0-8.4 days; p < 0.001). The difference in ICU length of stay for patients with nonoperative pelvis fractures was 0.8 days compared with ICU length of stay for patients with hip fractures (95% CI, 0.7-0.9 days; p < 0.001); 1.9 days for patients with acetabulum fractures (95% CI, 1.8-2.1 days; p < 0.001); and 6.3 days for patients with operative pelvic fractures (95% CI, 5.9-6.7 days; p < 0.001). The difference in mechanical ventilation time for patients with nonoperative fractures was 0.5 days compared with ventilation time for patients with hip fractures (95% CI, 0.4-0.6 days; p < 0.001); 1.1 days for patients with acetabulum fractures (95% CI, 1.0-1.2 days; p < 0.001); and 3.9 days for patients with operative fractures (95% CI, 2.5-3.2 days; p < 0.001). In our current multitiered trauma system, certain centers will see higher proportions of patients with acetabulum and operative pelvic fractures. Because hospitals are reimbursed equally for these subgroups of Medicare DRG 536, centers that care for a greater proportion of patients with more-complex pelvic trauma will experience lower financial margins per trauma patient, limiting their potential for growth and investment compared with competing institutions that may not routinely see patients with high-energy trauma. Because of this, we believe reevaluation of this Medicare Prospective Payment System DRG is warranted. Level IV, economic and decision analysis.

[Proposals for adapting a DRG system in the fields of orthopedics and trauma surgery for 2004].

PubMed

Roeder, N; Franz, D; Siebert, H; Frank, D; Stücker, R; Meiners, A; Tempka, A; Siebert, C H

2003-09-01

The introduction of the DRG system in Germany-optional since 1 January 2003 and mandatory for all hospitals as of 1 January 2004-has resulted in great uncertainty, particularly on the part of hospitals, since apprehension prevails that the diagnostic and therapeutic measures practiced in Germany will not be appropriately represented and remunerated by a DRG system. The G-DRG version 1.0 prepared within the framework of substitutive execution is largely identical to the Australian AR-DRG version 4.1. Adjustments that do justice to the realities of German treatment modalities were at most insignificant. It is therefore essential that stock be taken for each medical specialty to determine to what extent treatment procedures commonly followed in Germany are adequately reflected in this G-DRG system or whether adjustments are necessary to make allowances for German realities. To be able to provide qualified statements on the problems involved, scientific analysis of possible problems is necessary utilizing German data. Thus, we undertook an evaluation of how the special fields of orthopedics and accident surgery are represented in the G-DRG system. The resultant data form the basis for evidence of presumable deficits in the representation of orthopedic and accident surgery cases in the G-DRG system. The German Association for Trauma Surgery and the German Association for Orthopedics and Orthopedic Surgery have undertaken a DRG evaluation project together with the Organization of Directors for Accident Surgery (chairperson: Professor Dr. Mischkowsky, Kempten), the Organization of Directors for Orthopedics (chairperson: Professor Dr. Puhl, Ulm), the DRG Working Group of the German Association for Accident Surgery, and the Joint Commission of the Professional Association of German Surgeons and the German Association for Surgery in cooperation with the DRG Research Group of the University Clinic Muenster, the German Hospital Association, and the German Medical Association with the goal of examining the medical and economic homogeneity of the case groups. A total of 12,645 orthopedic and trauma surgery cases were collected from 23 clinics-11 university hospitals and 12 non-university hospitals-and assessed. On the basis of this database and when too few cases were evaluable also based on clinical considerations, 14 adjustment proposals were formulated and submitted on schedule on 31 March 2003 to the Institute for Hospital Remuneration. The results of the DRG evaluation project illustrated the problems involved in representing the exceedingly heterogeneous and complex activities of orthopedic and trauma surgery departments in a flat rate financing system that is not attuned to the realties of German treatment procedures. Version 1.0 of the G-DRG system is not sufficiently differentiated to represent the multifaceted diagnostic and therapeutic services provided by trauma surgery and orthopedic departments in Germany.

A new accounting system for financial balance based on personnel cost after the introduction of a DPC/DRG system.

PubMed

Nakagawa, Yoshiaki; Takemura, Tadamasa; Yoshihara, Hiroyuki; Nakagawa, Yoshinobu

2011-04-01

A hospital director must estimate the revenues and expenses not only in a hospital but also in each clinical division to determine the proper management strategy. A new prospective payment system based on the Diagnosis Procedure Combination (DPC/PPS) introduced in 2003 has made the attribution of revenues and expenses for each clinical department very complicated because of the intricate involvement between the overall or blanket component and a fee-for service (FFS). Few reports have so far presented a programmatic method for the calculation of medical costs and financial balance. A simple method has been devised, based on personnel cost, for calculating medical costs and financial balance. Using this method, one individual was able to complete the calculations for a hospital which contains 535 beds and 16 clinics, without using the central hospital computer system.

Lifting the weight of a diagnosis-related groups family change: a comparison between refined and non-refined DRG systems for top-down cost accounting and efficiency indicators.

PubMed

Zlotnik, Alexander; Cuchi, Miguel Alfaro; Pérez Pérez, Maria Carmen

Public healthcare providers in all Spanish Regions - Autonomous Communities (ACs) use All Patients Diagnosis-Related Groups (AP-DRGs) for billing non-insured patients, cost accounting and inpatient efficiency indicators. A national migration to All Patients Refined Diagnosis-Related Groups (APR-DRGs) has been scheduled for 2016. The analysis was performed on 202,912 inpatient care episodes ranging from 2005 to 2010. All episodes were grouped using AP-DRG v25.0 and APR-DRG v24.0. Normalised DRG weight variations for an AP-DRG to APR-DRG migration scenario were calculated and compared. Major differences exist between normalised weights for inpatient episodes depending on the DRGs family used. The usage of the APR-DRG system in Spain without any adjustments, as it was developed in the United States, should be approached with care. In order to avoid reverse incentives and provider financial risks, coding practices should be reviewed and structural differences between DRG families taken into account.

[Classification of severely injured patients in the G-DRG System 2008].

PubMed

Juhra, C; Franz, D; Roeder, N; Vordemvenne, T; Raschke, M J

2009-05-01

Since the introduction of a per-case reimbursement system in Germany (German Diagnosis-Related Groups, G-DRG), the correct reimbursement for the treatment of severely injured patients has been much debated. While the classification of a patient in a polytrauma DRG follows different rules than the usual clinical definition, leading to a high number of patients not grouped as severely injured by the system, the system was also criticized in 2005 for its shortcomings in financing the treatment of severely injured patients. The development of financial reimbursement will be discussed in this paper. 167 patients treated in 2006 and 2007 due to a severe injury at the University-Hospital Münster and grouped into a polytrauma-DRG were included in this study. For each patient, cost-equivalents were estimated. For those patients treated in 2007 (n=110), exact costs were calculated following the InEK cost-calculation method. The reimbursement was calculated using the G-DRG-Systems of 2007, 2008 and 2009. Cost-equivalents/costs and clinical parameters were correlated. A total of 167 patients treated in 2006 and 2007 for a severe injury at the Münster University Hospital and grouped into a polytrauma DRG were included in this study. Cost equivalents were estimated for each patient. For those patients treated in 2007 (n=110), exact costs were calculated following the InEK (Institute for the Hospital Remuneration System) cost calculation method. Reimbursement was calculated using the G-DRG systems of 2007, 2008 and 2009. Cost equivalents/costs and clinical parameters were correlated. With the ongoing development of the G-DRG system, reimbursement for the treatment of severely injured patient has improved, but the amount of underfinancing remains substantial. As treatment of severely injured patients must be reimbursed using the G-DRG system, this system must be further adapted to better meet the needs of severely injured patients. Parameters such as total surgery time, injury severity score (ISS) and LOS in ICU could be used for this purpose. In future, data obtained in trauma networks can help optimize reimbursement for the treatment of these patients.

Shaping the System - The DRG Evaluation Project of the German Society for Gynaecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG).

PubMed

Fiori, W; Renner, S P; Siam, K; Babapirali, J; Roeder, N; Dausch, E; Hildebrandt, T; Hillemanns, P; Nehmzow, M; Zygmunt, M; Piroth, D; Schem, C; Schwenzer, T; Friese, K; Wallwiener, D; Beckmann, M W

2013-08-01

Introduction: The German DRG system is annually adapted to the changing services provided. For the further development, the self-governing body and its DRG Institute (InEK) depend on participation of the users. Methods: For one of the DRG evaluation projects initiated by DGGG, cost and performance data for the year 2011 from 16 hospitals were available. After plausibility checks and corrections, analyses for service and cost homogeneity were performed. In cases of inadequate DRG-representation attributes were sought that would make an appropriate reimbursement possible. Conspicuities and potential solutions were checked for clinical plausibility. Results: 44 concrete modification proposals for further development of the G-DRG system were formulated and submitted in due time to the InEK. In addition, 3 modification proposals were addressed to the German Institute for Medical Documentation and Information (Deutsches Institut für Medizinische Dokumentation und Information, DIMDI) for further development of the diagnosis classification ICD-10-GM. For all modification proposals care was taken to minimise misdirected incentives and to reduce the potential for disputes with the cost bearers and their auditors services in settlements. Discussion: The publication of the G-DRG system 2014 shows which modification proposals have been realised. Essentially, an appropriate redistribution of the resources among the gynaecological and obstetrics departments is to be expected. The financial pressure that is caused by the generally inadequate financing of hospitals will not be reduced by a further development of the G-DRG system.

Shaping the System – The DRG Evaluation Project of the German Society for Gynaecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG)

PubMed Central

Fiori, W.; Renner, S. P.; Siam, K.; Babapirali, J.; Roeder, N.; Dausch, E.; Hildebrandt, T.; Hillemanns, P.; Nehmzow, M.; Zygmunt, M.; Piroth, D.; Schem, C.; Schwenzer, T.; Friese, K.; Wallwiener, D.; Beckmann, M. W.

2013-01-01

Introduction: The German DRG system is annually adapted to the changing services provided. For the further development, the self-governing body and its DRG Institute (InEK) depend on participation of the users. Methods: For one of the DRG evaluation projects initiated by DGGG, cost and performance data for the year 2011 from 16 hospitals were available. After plausibility checks and corrections, analyses for service and cost homogeneity were performed. In cases of inadequate DRG-representation attributes were sought that would make an appropriate reimbursement possible. Conspicuities and potential solutions were checked for clinical plausibility. Results: 44 concrete modification proposals for further development of the G-DRG system were formulated and submitted in due time to the InEK. In addition, 3 modification proposals were addressed to the German Institute for Medical Documentation and Information (Deutsches Institut für Medizinische Dokumentation und Information, DIMDI) for further development of the diagnosis classification ICD-10-GM. For all modification proposals care was taken to minimise misdirected incentives and to reduce the potential for disputes with the cost bearers and their auditors services in settlements. Discussion: The publication of the G-DRG system 2014 shows which modification proposals have been realised. Essentially, an appropriate redistribution of the resources among the gynaecological and obstetrics departments is to be expected. The financial pressure that is caused by the generally inadequate financing of hospitals will not be reduced by a further development of the G-DRG system. PMID:24771931

[Financing of inpatient orthopaedics and trauma surgery in the 2011 G-DRG System].

PubMed

Franz, D; Schemmann, F; Roeder, N; Siebert, H; Mahlke, L

2011-09-01

The German DRG system forms the basis for billing inpatient hospital services. It includes not only the case groups (G-DRGs), but also copayments. This paper analyses and evaluates the relevant developments of the 2011 G-DRG system for orthopaedics and traumatology from the medical and classificatory perspective. An analysis was performed of relevant diagnoses, medical procedures and G-DRGs in the 2010 and 2011 versions based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). A number of codes for surgical measures have been newly established or modified - above all in foot surgery, arthroscopic surgery and wound surgery. Here, the identification and the correct and performance-based mapping of complex and elaborate scenarios was again the focus of the restructuring of the G-DRG system. The G-DRG structure in orthopaedics and traumatology is changed, especially for polytraumata. The allocation of common cases with a standardized treatment pattern appears to be appropriate and the reimbursement adequate. For the less common and more complex cases the 2011 G-DRG system still shows need for further modification (e.g. polytraumata, joint replacement, spine surgery). The proper integration of the modified OPS classification for foot surgery to the appropriate G-DRGs will be essential to maintain the high quality of the reimbursement structure for the future.

[The possible drawbacks of applying the DRG classification].

PubMed

Huber, Zofia Swinarski

2006-09-06

The objective of this article is to present the difficulties linked to the measure and use of the Diagnosis Related Group (DRG) as part of a hospital's production and management accounting evaluation system. We will present here all the criticisms brought forth in management literature against DRG classifications. The article isn't intended to argue against and to push people to reconsider the tool but rather to attract the attention of politicians and hospital managers to all the possible difficulties and outcomes that could be generated by the DRG, this in terms of either the AP-DRG or the German-DRG, the latter being the classification that has been adopted in Switzerland as the basis for the construction of the future Swiss-DRG.

Post-stroke rehabilitation: an economic or medical priority? Current issues and prospects in light of new legislative regulations.

PubMed

Paolucci, S; Traballesi, M; Emberti Gialloreti, L; Pratesi, L; Lubich, S; Salvia, A; Grasso, M G; Morelli, D; Pulcini, M; Troisi, E; Coiro, P; Caltagirone, C

1998-02-01

The aim of this study was to evaluate: 1) whether the reduction in duration of in-patient rehabilitation imposed by the Italian Ministry of Health's circular of 29/6/95 has been accompanied by a decline in the results achieved; and 2) whether the system of basing payments on diagnosis related group (DRG) criteria is capable of correctly evaluating differences in post-stroke clinical pictures. The study involved 461 of 497 patients consecutively admitted between 1991 and 1996 for rehabilitation after a first stroke. The average duration of hospitalisation for the period 1995-1996 was significantly shorter (p<0.001) than that of the previous years; at the same time, there was a significant increase (p<0.05) in the number of poor responders in both neurological and functional (mobility) terms. Furthermore, the early discharge after 60 days of the 1995-1996 patients compromised the stabilisation of recovery and led to a subsequent functional decline. It is therefore hoped that the current regulations will be revised and that payments based on a functional related group (FRG) criterion will be introduced.

Mechanical hypersensitivity, sympathetic sprouting, and glial activation are attenuated by local injection of corticosteroid near the lumbar ganglion in a rat model of neuropathic pain.

PubMed

Li, Jing-Yi; Xie, Wenrui; Strong, Judith A; Guo, Qu-Lian; Zhang, Jun-Ming

2011-01-01

Inflammatory responses in the lumbar dorsal root ganglion (DRG) play a key role in pathologic pain states. Systemic administration of a common anti-inflammatory corticosteroid, triamcinolone acetonide (TA), reduces sympathetic sprouting, mechanical pain behavior, spontaneous bursting activity, and cytokine and nerve growth factor production in the DRG. We hypothesized that systemic TA effects are primarily due to local effects on the DRG. Male Sprague-Dawley rats were divided into 4 groups: SNL (tight ligation and transection of spinal nerves) and normal with and without a single dose of TA injectable suspension slowly injected onto the surface of DRG and surrounding region at the time of SNL or sham surgery. Mechanical threshold was tested on postoperative days 1, 3, 5, and 7. Immunohistochemical staining examined tyrosine hydroxylase and glial fibrillary acidic protein in DRG and CD11B antibody (OX-42) in spinal cord. Local TA treatment attenuated mechanical sensitivity, reduced sympathetic sprouting in the DRG, and decreased satellite glia activation in the DRG and microglia activation in the spinal cord after SNL. A single injection of corticosteroid in the vicinity of the axotomized DRG can mimic many effects of systemic TA, mitigating behavioral and cellular abnormalities induced by spinal nerve ligation. This provides a further rationale for the use of localized steroid injections clinically and provides further support for the idea that localized inflammation at the level of the DRG is an important component of the spinal nerve ligation model, commonly classified as neuropathic pain model.

Evaluation of Large-scale Data to Detect Irregularity in Payment for Medical Services. An Extended Use of Benford's Law.

PubMed

Park, Junghyun A; Kim, Minki; Yoon, Seokjoon

2016-05-17

Sophisticated anti-fraud systems for the healthcare sector have been built based on several statistical methods. Although existing methods have been developed to detect fraud in the healthcare sector, these algorithms consume considerable time and cost, and lack a theoretical basis to handle large-scale data. Based on mathematical theory, this study proposes a new approach to using Benford's Law in that we closely examined the individual-level data to identify specific fees for in-depth analysis. We extended the mathematical theory to demonstrate the manner in which large-scale data conform to Benford's Law. Then, we empirically tested its applicability using actual large-scale healthcare data from Korea's Health Insurance Review and Assessment (HIRA) National Patient Sample (NPS). For Benford's Law, we considered the mean absolute deviation (MAD) formula to test the large-scale data. We conducted our study on 32 diseases, comprising 25 representative diseases and 7 DRG-regulated diseases. We performed an empirical test on 25 diseases, showing the applicability of Benford's Law to large-scale data in the healthcare industry. For the seven DRG-regulated diseases, we examined the individual-level data to identify specific fees to carry out an in-depth analysis. Among the eight categories of medical costs, we considered the strength of certain irregularities based on the details of each DRG-regulated disease. Using the degree of abnormality, we propose priority action to be taken by government health departments and private insurance institutions to bring unnecessary medical expenses under control. However, when we detect deviations from Benford's Law, relatively high contamination ratios are required at conventional significance levels.

[Expressional change of nitric oxide synthases in dorsal root ganglia of cats after selective dorsal rhizotomy].

PubMed

Qin, Hua-li; Zhou, Xue; Zhang, Wei; Chen, Si-xiu

2004-01-01

To examine the expressional change of nitric oxide synthase (NOS) in the injured dorsal root ganglia (DRG) and the ipsilateral adjacent uninjured DRG after selective dorsal rhizotomy. Immunochemical ABC method was used to detect the distribution of immunoreaction complex of NOS isoforms--nNOS and eNOS, and quantitative analysis was conducted to get the number of nNOS-immunoreactivity (nNOS-IR) neurons in normal DRG, dorsal rhizotomized DRG and spared DRG from adult cats on the 6th day after operation. This operating model was made by rhizotomizing unilateral L1-L5 dorsal roots and leaving L6 as a spared root. nNOS-immunoreactants were mainly distributed in the small-sized neurons in the DRG of cat. The percentage of nNOS-expressing small-sized neurons increased in the deafferentated L5 DRG (29.74%) when compared with the contralateral DRG (19.35%), and it also increased in the spared DRG (24.22%), compared with the contralateral DRG (18.61%). eNOS-IR was not observed in the DRG of adult cats. nNOS/NO up-regulated in DRG neurons is involved in a wide variety of biological functions under physiological and lesion-induced pathophysiological conditions in nerve system.

Review of medical discharge summaries and medical documentation in a metropolitan hospital: impact on diagnostic-related groups and Weighted Inlier Equivalent Separation.

PubMed

Chin, N; Perera, P; Roberts, A; Nagappan, R

2013-07-01

Accurate and comprehensive clinical documentation is crucial for effective ongoing patient care, follow up and to optimise case mix-based funding. Each Diagnostic Related Group (DRG) is assigned a 'weight', leading to Weighted Inlier Equivalent Separation (WIES), a system many public and private hospitals in Australia subscribe to. To identify the top DRG in a general medical inpatient service, the completeness of medical discharge documentation, commonly missed comorbidities and system-related issues and subsequent impact on DRG and WIES allocation. One hundred and fifty completed discharge summaries were randomly selected from the top 10 medical DRG in our health service. From a detailed review of the clinical documentation, principal diagnoses, associated comorbidities and complications, where appropriate, the DRG and WIES were modified. Seventy-two (48%) of the 150 reviewed admissions resulted in a revision of DRG and WIES equivalent to an increase of AUD 142,000. Respiratory-based DRG generated the largest revision of DRG and WIES, while 'Cellulitis' DRG had the largest relative change. Twenty-seven per cent of summaries reviewed necessitated a change in coding with no subsequent change in DRG allocation or WIES. Acute renal failure, anaemia and electrolyte disturbances were the most commonly underrepresented entities in clinical discharge documentation. Seven patients had their WIES downgraded. Comprehensive documentation of principal diagnosis/diagnoses, comorbidities and their complications is imperative to optimal DRG and WIES allocation. Regular meetings between clinical and coding staff improve the quality and timeliness of medical documentation, ensure adequate communication with general practitioners and lead to appropriate funding. © 2013 The Authors; Internal Medicine Journal © 2013 Royal Australasian College of Physicians.

Towards An Improvement of Hospital Services and Streamlining of Health Care Costs: The DRG Analysis in Italy.

PubMed

Bellavia, M; Tomasello, G; Damiani, P; Damiani, F; Geraci, A; Accardo, Fm; Gioviale, Mc; Lo Monte, Ai

2012-01-01

The term Diagnosis-related Group (DRG) refers to a classification system used to assess hospital services with the aim of a better management of health care costs and improving performance. The DRG system focuses on the utilization of resources, and is not concerned with the specific type of care provided to the patient. This system highlights any diseconomies and eventual critical aspects of the hospital system. This article, starting from the history of heath care financing in Italy and pointing out the difficulty to define the "quality" of health care services, describes the variables used to evaluate correctly hospital performance based on the DRG system. These include Average Length of Stay, Average Daily Patient Load, Comparative Performance Index, and Case Mix Index.

[Possibilities and limitations for the representation of ENT medicine in the G-DRG reimbursement system. Results of the DRG evaluation project].

PubMed

Franz, D; Roeder, N; Hörmann, K; Alberty, J

2006-03-01

To improve the representation of ENT medicine in the German diagnosis related groups (G-DRG) reimbursement system, the German Association for ENT Medicine and the ENT Professional Medical Association, in cooperation with the DRG-Research Group of the University Hospital of Muenster, undertook a DRG evaluation project. A retrospective analysis was carried out of the DRG data records from 93,605 cases taken at 39 ENT institutions in 2003. A prospective collection of data from 25,666 cases, including defined expenditure data within a 4 month period in 2004, was also made. The number of cases per ENT institution ranged from 274 to 2,556. The mean case-mix was 792.0 and the mean case-mix index was 0.84. A total of 60.5% of the patients were male and 39.5% female, with an average age of 43.3 years. The mean patient clinical and complexity level (PCCL) was 0.72. Considerable adjustments have to be made, especially in oto-, rhino- and sinus-surgery. Allocation according to the complexity of the surgical procedure is mandatory and requires a revision of the German Catalogue of Medical Procedures. A DRG differentiation based on the PCCL should be implemented more frequently. Diagnostic endoscopies should be allocated via surgical partitioning. The adjustment proposals based on these results will gradually lead to an improved allocation of ENT medical procedures within the G-DRG system in 2006 and later.

[Quality of case allocation of orthopedics and trauma surgery in the 2004 and 2014 versions of the German DRG system. An interim assessment of the development process].

PubMed

Franz, D; Schemmann, F; Selter, D D; Auhuber, T; Gehweiler, D; Roeder, N; Siebert, H; Mahlke, L

2014-10-01

Since 2004 the German diagnosis-related groups (DRG) system has been applied nationwide in all German somatic hospitals. The G-DRG system is updated annually in order to increase the quality of case allocation. What developments have occurred since 2004 from the perspective of orthopedics and trauma surgery? This article takes stock of the developments between 2004 and 2014. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2004 and 2014 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). The number of G-DRGs in the whole system increased by 45.1 % between 2004 and 2014. The number of G-DRGs in the major diagnostic category (MDC) 08 that contains the majority of orthopedic and trauma surgery categories increased in the same period by 61.6 %. The reduction of variance of inlier costs in the MDC 08 category, a statistical measure of the performance of the G-DRG system, was below the corresponding value of the total system in 2004 as well in 2014. However, the reduction of variance of inlier costs in MDC 08 (+ 30.0 %) rose more from 2004 to 2014 than the corresponding value of the overall system (+ 21.5 %). Many modifications of the classification systems of diagnoses (ICD-10-GM) and medical procedures (OPS) and the structures of the G-DRG system could significantly improve the quality of case allocation from the perspective of orthopedics and trauma surgery between 2004 and 2014. Th assignment of cases could be differentiated so that complex cases with more utilization of resources were allocated to higher rated G-DRGs and vice versa. However, further improvements of the G-DRG system are necessary. Only correct and complete documentation and coding can provide a high quality of calculation of costs as a basis for a correct case allocation in future G-DRG systems.

Introducing diagnosis-related groups: is the information system ready?

PubMed

Jian, Weiyan; Lu, Ming; Han, Wei; Hu, Mu

2016-01-01

Diagnosis-related group (DRG) system is a classification system widely used in health managements, the foundation of which lies in the medical information system. A large effort had been made to improve the quality of discharge data before the introduction of DRGs in Beijing. We extract discharge data from 108 local hospitals spanning 4 years before and after standardization to evaluate the impact of standardization on DRG grouping performance. The data was grouped on an annual basis in accordance with Beijing's local DRG system. Proportion of ungrouped data, coefficient of variation (CV) and reduction in variance (RIV) were used to measure the performance of the DRG system. Both the descriptive and regression analysis indicate a significant reduction in terms of ungrouped data and CV for expenditure, increase of RIV for expenditure and length of stay. However, when there was no intervention, that is, between 2005 and 2006 and between 2008 and 2009, changes in these indicators were all insignificant. Therefore, the standardization of discharge data did improve data quality and consequently enhanced the performance of DRGs. Developing countries with a relatively weak information infrastructure should strengthen their medical information system before the introduction of the DRG system. Copyright © 2014 John Wiley & Sons, Ltd.

["Something humane has been lost". Re-evaluation of the attitudes of senior physicians towards the G-DRG System - a qualitative normative analysis].

PubMed

Knoll, Marco; Otte, Ina; Salloch, Sabine; Ruiner, Caroline; Kruppa, Esta; Vollmann, Jochen

2018-04-01

Only a few years after the implementation of the G-DRG (German Diagnosis Related Group) system physicians already began to complain of its negative effects on the quality of inpatient healthcare. The present study examines the recent experiences senior physicians have made with regard to the impact of the G-DRG system on the quality of healthcare and medical professionalism. Nine qualitative guided expert interviews were conducted focusing on the experiences of physicians in leading positions dealing with the G-DRG system in their everyday work. The interviewees report an intensification of work attributable to an increasing number of inpatient cases, a more lenient definition of medical indications and a reduction in patient retention time. The physicians interviewed have felt increasingly constrained by economic conditions. Additionally, they stated that the G-DRG system's incentive structure encourages the discrimination of older, care-dependent and multimorbid patients. Possible countermeasures include a political revision of incentive regulation as well as a strengthening of up-to-date professional ethical education and teaching. Copyright © 2018. Published by Elsevier GmbH.

[How can the coding quality in the DRG system be determined?].

PubMed

Kahlmeyer, A; Volkmer, B

2014-01-01

The permanent adjustments ​​since 2003 to the G-DRG system have made the system even less understandable, so that many users have the feeling of feeding data into a black box which gives them a result without them being able to actively use the system itself. While chief physicians, senior physicians, and nursing managers are responsible to management for the results of the billing, they are in most cases not involved in the steps of DRG coding and billing. From this situation, a common question arises: "How well does my department code?" This uncertainty is exploited by many commercial vendors, who offer a wide variety of approaches for DRG optimization. The goal of this work is to provide advice as to how coding quality can be determined.

Title: Comparative transcriptome profiling of the human and mouse dorsal root ganglia: an RNA-seq-based resource for pain and sensory neuroscience research.

PubMed

Ray, Pradipta; Torck, Andrew; Quigley, Lilyana; Wangzhou, Andi; Neiman, Matthew; Rao, Chandranshu; Lam, Tiffany; Kim, Ji-Young; Kim, Tae Hoon; Zhang, Michael Q; Dussor, Gregory; Price, Theodore J

2018-03-20

Molecular neurobiological insight into human nervous tissues is needed to generate next generation therapeutics for neurological disorders like chronic pain. We obtained human Dorsal Root Ganglia (DRG) samples from organ donors and performed RNA-sequencing (RNA-seq) to study the human DRG (hDRG) transcriptional landscape, systematically comparing it with publicly available data from a variety of human and orthologous mouse tissues, including mouse DRG (mDRG). We characterized the hDRG transcriptional profile in terms of tissue-restricted gene co-expression patterns and putative transcriptional regulators, and formulated an information-theoretic framework to quantify DRG enrichment. Relevant gene families and pathways were also analyzed, including transcription factors (TFs), g-protein coupled receptors (GCPRs) and ion channels. Our analyses reveal a hDRG-enriched protein-coding gene set (∼140), some of which have not been described in the context of DRG or pain signaling. A majority of these show conserved enrichment in mDRG, and were mined for known drug - gene product interactions. Conserved enrichment of the vast majority of TFs suggest that the mDRG is a faithful model system for studying hDRGs, due to evolutionarily conserved regulatory programs. Comparison of hDRG and tibial nerve transcriptomes suggest trafficking of neuronal mRNA to axons in adult hDRG, and are consistent with studies of axonal transport in rodent sensory neurons. We present our work as an online, searchable repository (https://www.utdallas.edu/bbs/painneurosciencelab/sensoryomics/drgtxome), creating a resource for the community. Our analyses provide insight into DRG biology for guiding development of novel therapeutics, and a blueprint for cross-species transcriptomic analyses.

Assessing DRG cost accounting with respect to resource allocation and tariff calculation: the case of Germany

PubMed Central

2012-01-01

The purpose of this paper is to analyze the German diagnosis related groups (G-DRG) cost accounting scheme by assessing its resource allocation at hospital level and its tariff calculation at national level. First, the paper reviews and assesses the three steps in the G-DRG resource allocation scheme at hospital level: (1) the groundwork; (2) cost-center accounting; and (3) patient-level costing. Second, the paper reviews and assesses the three steps in G-DRG national tariff calculation: (1) plausibility checks; (2) inlier calculation; and (3) the “one hospital” approach. The assessment is based on the two main goals of G-DRG introduction: improving transparency and efficiency. A further empirical assessment attests high costing quality. The G-DRG cost accounting scheme shows high system quality in resource allocation at hospital level, with limitations concerning a managerially relevant full cost approach and limitations in terms of advanced activity-based costing at patient-level. However, the scheme has serious flaws in national tariff calculation: inlier calculation is normative, and the “one hospital” model causes cost bias, adjustment and representativeness issues. The G-DRG system was designed for reimbursement calculation, but developed to a standard with strategic management implications, generalized by the idea of adapting a hospital’s cost structures to DRG revenues. This combination causes problems in actual hospital financing, although resource allocation is advanced at hospital level. PMID:22935314

Adult Mouse DRG Explant and Dissociated Cell Models to Investigate Neuroplasticity and Responses to Environmental Insults Including Viral Infection.

PubMed

Fornaro, Michele; Sharthiya, Harsh; Tiwari, Vaibhav

2018-03-09

This protocol describes an ex vivo model of mouse-derived dorsal root ganglia (DRG) explant and in vitro DRG-derived co-culture of dissociated sensory neurons and glial satellite cells. These are useful and versatile models to investigate a variety of biological responses associated with physiological and pathological conditions of the peripheral nervous system (PNS) ranging from neuron-glial interaction, neuroplasticity, neuroinflammation, and viral infection. The usage of DRG explant is scientifically advantageous compared to simplistic single cells models for multiple reasons. For instance, as an organotypic culture, the DRG explant allows ex vivo transfer of an entire neuronal network including the extracellular microenvironment that play a significant role in all the neuronal and glial functions. Further, DRG explants can also be maintained ex vivo for several days and the culture conditions can be perturbed as desired. In addition, the harvested DRG can be further dissociated into an in vitro co-culture of primary sensory neurons and satellite glial cells to investigate neuronal-glial interaction, neuritogenesis, axonal cone interaction with the extracellular microenvironment, and more general, any aspect associated with the neuronal metabolism. Therefore, the DRG-explant system offers a great deal of flexibility to study a wide array of events related to biological, physiological, and pathological conditions in a cost-effective manner.

Assessing DRG cost accounting with respect to resource allocation and tariff calculation: the case of Germany.

PubMed

Vogl, Matthias

2012-08-30

The purpose of this paper is to analyze the German diagnosis related groups (G-DRG) cost accounting scheme by assessing its resource allocation at hospital level and its tariff calculation at national level. First, the paper reviews and assesses the three steps in the G-DRG resource allocation scheme at hospital level: (1) the groundwork; (2) cost-center accounting; and (3) patient-level costing. Second, the paper reviews and assesses the three steps in G-DRG national tariff calculation: (1) plausibility checks; (2) inlier calculation; and (3) the "one hospital" approach. The assessment is based on the two main goals of G-DRG introduction: improving transparency and efficiency. A further empirical assessment attests high costing quality. The G-DRG cost accounting scheme shows high system quality in resource allocation at hospital level, with limitations concerning a managerially relevant full cost approach and limitations in terms of advanced activity-based costing at patient-level. However, the scheme has serious flaws in national tariff calculation: inlier calculation is normative, and the "one hospital" model causes cost bias, adjustment and representativeness issues. The G-DRG system was designed for reimbursement calculation, but developed to a standard with strategic management implications, generalized by the idea of adapting a hospital's cost structures to DRG revenues. This combination causes problems in actual hospital financing, although resource allocation is advanced at hospital level.

[Case allocation of extensive operations on head and neck within the German DRG system 2004-2007: what is the net result of the continued developments in case allocation?].

PubMed

Franz, D; Franz, K; Roeder, N; Hörmann, K; Fischer, R-J; Alberty, Jürgen

2007-07-01

When the German DRG system was implemented there was some doubt about whether patients with extensive head and neck surgery would be properly accounted for. Significant efforts have therefore been invested in analysis and case allocation of those in this group. The object of this study was to investigate whether the changes within the German DRG system have led to improved case allocation. Cost data received from 25 ENT departments on 518 prospective documented cases of extensive head and neck surgery were compared with data from the German institute dealing with remuneration in hospitals (InEK). Statistical measures used by InEK were used to analyse the quality of the overall system and the homogeneity of the individual case groups. The reduction of variance of inlier costs improved by about 107.3% from the 2004 version to the 2007 version of the German DRG system. The average coefficient of cost homogeneity rose by about 9.7% in the same period. Case mix index and DRG revenues were redistributed from less extensive to the more complex operations. Hospitals with large numbers of extensive operations and university hospitals will gain most benefit from this development. Appropriate case allocation of extensive operations on the head and neck has been improved by the continued development of the German DRG system culminating in the 2007 version. Further adjustments will be needed in the future.

[Cardiovascular medicine in the German diagnosis-related group--(G-DRG) system 2005].

PubMed

Fürstenberg, T; Bunzemeier, H; Roeder, N; Reinecke, H

2005-05-01

The German diagnosis-related Group (G-DRG) System has recently been published in its third version. From 2005 on, this system will be the definite measure for the budgets of nearly all german hospitals. The preliminary phase with no budget reduction or redistribution being made and in which an inappropriate classification system had no negative impact on reimbursement has, thus, come to an end. At present, many hospitals are struggling in an economic competition about the independence or maintenance of the hospital or several sub-departments. The changes in the classification system with regard to a marked increase in the number of G DRGs, a modified grouping-logic, more properly determined reductions and extra charges for low and high outlier as well as the introduction of further additional charges contribute thereby to a better covering of services and treatments of cardiovascular patients. However, while many of the known problems have been eliminated, there are still weaknesses in the G-DRG System even concerning cardiovascular medicine. The G-DRG System has to be adapted continuously with consultation of the clinical expertise of the respective medical societies. The most important new aspects and changes in the G-DRG System 2005 and the accompanied execution regulations are explained with special view on cardiology.

The implementation of DRG-based hospital reimbursement in Switzerland: A population-based perspective.

PubMed

Busato, André; von Below, Georg

2010-10-16

Switzerland introduces a DRG (Diagnosis Related Groups) based system for hospital financing in 2012 in order to increase efficiency and transparency of Swiss health care. DRG-based hospital reimbursement is not simultaneously realized in all Swiss cantons and several cantons already implemented DRG-based financing irrespective of the national agenda, a setting that provides an opportunity to compare the situation in different cantons. Effects of introducing DRGs anticipated for providers and insurers are relatively well known but it remains less clear what effects DRGs will have on served populations. The objective of the study is therefore to analyze differences of volume and major quality indicators of care between areas with or without DRG-based hospital reimbursement from a population based perspective. Small area analysis of all hospitalizations in acute care hospitals and of all consultations reimbursed by mandatory basic health insurance for physicians in own practice during 2003-2007. The results show fewer hospitalizations and a relocation of resources to outpatient care in areas with DRG reimbursement. Overall burden of disease expressed as per capita DRG cost weights was almost identical between the two types of hospital reimbursement and no distinct temporal differences were detected in this respect. But the results show considerably higher 90-day rehospitalization rates in DRG areas. The study provides evidence of both desired and harmful effects related to the implementation of DRGs. Systematic monitoring of outcomes and quality of care are therefore essential elements to maintain in the Swiss health system after DRG's are implemented on a nationwide basis in 2012.

Systematically evaluating the impact of diagnosis-related groups (DRGs) on health care delivery: a matrix of ethical implications.

PubMed

Fourie, Carina; Biller-Andorno, Nikola; Wild, Verina

2014-04-01

Swiss hospitals were required to implement a prospective payment system for reimbursement using a diagnosis-related groups (DRGs) classification system by the beginning of 2012. Reforms to a health care system should be assessed for their impact, including their impact on ethically relevant factors. Over a number of years and in a number of countries, questions have been raised in the literature about the ethical implications of the implementation of DRGs. However, despite this, researchers have not attempted to identify the major ethical issues associated with DRGs systematically. To address this gap in the literature, we have developed a matrix for identifying the ethical implications of the implementation of DRGs. It was developed using a literature review, and empirical studies on DRGs, as well as a review and analysis of existing ethics frameworks. The matrix consists of the ethically relevant parameters of health care systems on which DRGs are likely to have an impact; the ethical values underlying these parameters; and examples of specific research questions associated with DRGs to illustrate how the matrix can be applied. While the matrix has been developed in light of the Swiss health care reform, it could be used as a basis for identifying the ethical implications of DRG-based systems worldwide and for highlighting the ethical implications of other kinds of provider payment systems (PPS). Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Adult DRG Stem/Progenitor Cells Generate Pericytes in the Presence of Central Nervous System (CNS) Developmental Cues, and Schwann Cells in Response to CNS Demyelination.

PubMed

Vidal, Marie; Maniglier, Madlyne; Deboux, Cyrille; Bachelin, Corinne; Zujovic, Violetta; Baron-Van Evercooren, Anne

2015-06-01

It has been proposed that the adult dorsal root ganglia (DRG) harbor neural stem/progenitor cells (NPCs) derived from the neural crest. However, the thorough characterization of their stemness and differentiation plasticity was not addressed. In this study, we investigated adult DRG-NPC stem cell properties overtime, and their fate when ectopically grafted in the central nervous system. We compared them in vitro and in vivo to the well-characterized adult spinal cord-NPCs derived from the same donors. Using micro-dissection and neurosphere cultures, we demonstrate that adult DRG-NPCs have quasi unlimited self-expansion capacities without compromising their tissue specific molecular signature. Moreover, they differentiate into multiple peripheral lineages in vitro. After transplantation, adult DRG-NPCs generate pericytes in the developing forebrain but remyelinating Schwann cells in response to spinal cord demyelination. In addition, we show that axonal and endothelial/astrocytic factors as well astrocytes regulate the fate of adult DRG-NPCs in culture. Although the adult DRG-NPC multipotency is restricted to the neural crest lineage, their dual responsiveness to developmental and lesion cues highlights their impressive adaptive and repair potentials making them valuable targets for regenerative medicine. © 2015 AlphaMed Press.

Recommendations for the classification of HIV associated neuromanifestations in the German DRG system.

PubMed

Evers, Stefan; Fiori, W; Brockmeyer, N; Arendt, G; Husstedt, I-W

2005-09-12

HIV associated neuromanifestations are of growing importance in the in-patient treatment of HIV infected patients. In Germany, all in-patients have to be coded according to the ICD-10 classification and the German DRG-system. We present recommendations how to code the different primary and secondary neuromanifestations of HIV infection. These recommendations are based on the commentary of the German DRG procedures and are aimed to establish uniform coding of neuromanifestations.

Axonal outgrowth, neuropeptides expression and receptors tyrosine kinase phosphorylation in 3D organotypic cultures of adult dorsal root ganglia

PubMed Central

Alves, Cecília J.; Leitão, Luís; Sousa, Daniela M.; Alencastre, Inês S.; Conceição, Francisco; Lamghari, Meriem

2017-01-01

Limited knowledge from mechanistic studies on adult sensory neuronal activity was generated, to some extent, in recapitulated adult in vivo 3D microenvironment. To fill this gap there is a real need to better characterize the adult dorsal root ganglia (aDRG) organotypic cultures to make these in vitro systems exploitable for different approaches, ranging from basic neurobiology to regenerative therapies, to address the sensory nervous system in adult stage. We conducted a direct head-to-head comparison of aDRG and embryonic DRG (eDRG) organotypic culture focusing on axonal growth, neuropeptides expression and receptors tyrosine kinase (RTK) activation associated with neuronal survival, proliferation and differentiation. To identify alterations related to culture conditions, these parameters were also addressed in retrieved aDRG and eDRG and compared with organotypic cultures. Under similar neurotrophic stimulation, aDRG organotypic cultures displayed lower axonal outgrowth rate supported by reduced expression of growth associated protein-43 and high levels of RhoA and glycogen synthase kinase 3 beta mRNA transcripts. In addition, differential alteration in sensory neuropeptides expression, namely calcitonin gene-related peptide and substance P, was detected and was mainly pronounced at gene expression levels. Among 39 different RTK, five receptors from three RTK families were emphasized: tropomyosin receptor kinase A (TrkA), epidermal growth factor receptors (EGFR, ErbB2 and ErbB3) and platelet-derived growth factor receptor (PDGFR). Of note, except for EGFR, the phosphorylation of these receptors was dependent on DRG developmental stage and/or culture condition. In addition, EGFR and PDGFR displayed alterations in their cellular expression pattern in cultured DRG. Overall we provided valuable information particularly important when addressing in vitro the molecular mechanisms associated with development, maturation and regeneration of the sensory nervous system. PMID:28742111

[Assessment of Coding in German Diagnosis Related Groups System in Otorhinolaryngology].

PubMed

Ellies, Maik; Anders, Berit; Seger, Wolfgang

2018-05-14

Prospective analysis of assessment reports in otorhinolaryngology for the period 01-03-2011 to 31-03-2017 by the Health Advisory Boards in Lower Saxony and Bremen, Germany in relation to coding in the G-DRG-System. The assessment reports were documented using a standardized database system developed on the basis of the electronic data exchange (DTA) by the Health Advisory Board in Lower Saxony. In addition, the documentation of the assessment reports according to the G-DRG system was used for assessment. Furthermore, the assessment of a case was evaluated once again on the basis of the present assessment documents and presented as an example in detail. During the period from 01-03-2011 to 31-03-2017, a total of 27,424 cases of inpatient assessments of DRGs according to the G-DRG system were collected in the field of otorhinolaryngology. In 7,259 cases, the DRG was changed, and in 20,175 cases, the suspicion of a DRG-relevant coding error was not justified in the review; thus, a DRG change rate of 26% of the assessments was identified over the time period investigated. There were different kinds of coding errors. In order to improve the coding quality in otorhinolaryngology, in addition to the special consideration of the presented "hit list" by the otorhinolaryngology departments, there should be more intensive cooperation between hospitals and the Health Advisory Boards of the federal states. © Georg Thieme Verlag KG Stuttgart · New York.

[Insufficient funding of nursing service in paediatrics. The case of the DRG E77C].

PubMed

Herrmann, René; Fusch, Christoph; Flessa, Steffen

2008-09-01

For most of the existing German Diagnosis Related Groups (G-DRG) the German generalised compensation system for medical services in hospitals does not distinguish between children and adults. There is a risk of the cost of high-maintenance paediatric patients not being covered. This problem is tried to be solved by implementing a split based on the patient's age. Thus children under the age of one year will be classified to a different DRG than older patients with the same diagnosis. A study of working time combined with an analysis of the so-called "Pflegepersonalregelung-Minuten" carried out by the Ernst-Moritz-Arndt University of Greifswald exemplarily shows the different intenseness of care between paediatric and adult patients. Furthermore, the different intenseness of care correlates with the labour cost of the university hospital and shows the extensions of the shortfall for the most profitable DRG based on guidelines of the "Institut für das Entgeltsystem im Krankenhaus" (Institute for the compensation system in hospitals, InEK). Last but not least it discusses if the age-splitting planned for the 2008 DRG-Catalogue might improve the financial situation. Moreover the authors point out possibilities for a proper compensation for paediatrics in the G-DRG system.

Glial cells isolated from dorsal root ganglia express prostaglandin E(2) (EP(4)) and prostacyclin (IP) receptors.

PubMed

Ng, Kai Yu; Wong, Yung Hou; Wise, Helen

2011-07-01

Isolated cells from adult rat dorsal root ganglia (DRG) are frequently used as a model system to study responses of primary sensory neurons to nociceptor sensitizing agents such as prostaglandin E(2) and prostacyclin, which are presumed to act only on the neurons in typical mixed cell cultures. In the present study, we evaluated the expression of prostaglandin E(2) (EP(4)) and prostacyclin (IP) receptors in cultures of mixed DRG cells and in purified DRG glia. We show here that EP(4) and IP receptor agonists stimulated adenylyl cyclase activity in both mixed DRG cells and in purified DRG glia, and that these responses were specifically inhibited by EP(4) and IP receptor antagonists, respectively. The presence of EP(4) and IP receptors in DRG glia was further confirmed by the expression of EP(4) and IP receptor immunoreactivity and mRNA. With the increasing awareness of neuron-glial interactions within intact DRG and the use of isolated DRG cells in the study of mechanisms underlying nociception, it will be essential to consider the role played by EP(4) and IP receptor-expressing glial cells when evaluating prostanoid-induced sensitization of DRG neurons. Copyright © 2011 Elsevier B.V. All rights reserved.

[How does the German DRG system differentiate and reimburse vitreoretinal surgery in diabetic patients?].

PubMed

Krause, M; Goldschmidt, A J; Berg, M; Kropf, S; Sachs, A; Gatzioufas, Z; Brückner, K; Seitz, B

2008-10-01

The German DRG system (G-DRG system) is required to assign medical cases with similar costs correctly into a particular group, each case within the group receiving the same amount of reimbursement. At the same time the system should allow all-inclusive reimbursement, not necessarily reflecting the exact costs of each case. These opposite goals and the so far limited calculation basis raise the question of how the G-DRG system actually processes and reimburses empirically collected in-hospital treatment data. In 2005, 112 patients were admitted to the University Eye Hospital, University of the Saarland. All patients had diabetic retinopathy and required at least one vitreoretinal procedure. Demographic and clinical data were collected by using the hospital information system and the coding software KODIP. For statistic evaluation, principal diagnoses, ancillary diagnoses and procedures were each reassigned to particular groups. Reimbursement was calculated based on the case data of the year 2005. Also, the case data were reassigned with respect to calculation of reimbursement for the years 2006 and 2007. The results were compared with federal G-DRG calculation data. Mean age of the patients was 65.8 +/- 11.1 years, length of stay in-hospital was 9.3 +/- 3.2 days. In the 66 patients requiring general anaesthesia the cumulative length of stay in the operation room was 148.4 +/- 39.5 minutes, the cumulative duration of surgery was 86.3 +/- 34.1 minutes. In the 50 patients requiring local anaesthesia the cumulative length of stay in the operation room was 137.8 +/- 51.8 minutes, the cumulative duration of surgery was 81.6 +/- 43.6 minutes. The patients had 1.9 +/- 0.8 principal diagnoses, 14.4 +/- 5.8 ancillary diagnoses and 3.4 +/- 1.6 procedures. Twenty-five of 112 patients (22.3 %) were assigned to DRG C 03Z (1), 82 of 112 patients (73.2 %) were assigned to DRG C 17Z (2). Five patients were assigned to other DRG. Compared with the federal calculation data, our own data for 2005, 2006 and 2007 showed more high primary clinical complexity levels and a longer duration of in-hospital stay. For each of the three years the amount of reimbursement was equal in about two thirds of the own patients. Reimbursement was only differentiated for outliers beyond the trim point of the duration of in-hospital stay. The demographic and clinical G-DRG data of the included patients showed substantial cost-effective inhomogeneities. These inhomogeneities were not sufficiently considered for reimbursement based upon Z-DRG. Specialised departments with higher numbers of difficult cases may be discriminated. Wrong incentives may result in the selection of "low-risk cases".

Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States Medicare population: potential economic implications of a new minimally-invasive technology

PubMed Central

Ackerman, Stacey J; Polly, David W; Knight, Tyler; Schneider, Karen; Holt, Tim; Cummings, John

2013-01-01

Introduction The economic burden associated with the treatment of low back pain (LBP) in the United States is significant. LBP caused by sacroiliac (SI) joint disruption/degenerative sacroiliitis is most commonly treated with nonoperative care and/or open SI joint surgery. New and effective minimally invasive surgery (MIS) options may offer potential cost savings to Medicare. Methods An economic model was developed to compare the costs of MIS treatment to nonoperative care for the treatment of SI joint disruption in the hospital inpatient setting in the US Medicare population. Lifetime cost savings (2012 US dollars) were estimated from the published literature and claims data. Costs included treatment, follow-up, diagnostic testing, and retail pharmacy pain medication. Costs of SI joint disruption patients managed with nonoperative care were estimated from the 2005–2010 Medicare 5% Standard Analytic Files using primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes 720.2, 724.6, 739.4, 846.9, or 847.3. MIS fusion hospitalization cost was based on Diagnosis Related Group (DRG) payments of $46,700 (with major complications - DRG 459) and $27,800 (without major complications - DRG 460), weighted assuming 3.8% of patients have complications. MIS fusion professional fee was determined from the 2012 Medicare payment for Current Procedural Terminology code 27280, with an 82% fusion success rate and 1.8% revision rate. Outcomes were discounted by 3.0% per annum. Results The extrapolated lifetime cost of treating Medicare patients with MIS fusion was $48,185/patient compared to $51,543/patient for nonoperative care, resulting in a $660 million savings to Medicare (196,452 beneficiaries at $3,358 in savings/patient). Including those with ICD-9-CM code 721.3 (lumbosacral spondylosis) increased lifetime cost estimates (up to 478,764 beneficiaries at $8,692 in savings/patient). Conclusion Treating Medicare beneficiaries with MIS fusion in the hospital inpatient setting could save Medicare $660 million over patients’ lifetimes. PMID:24348055

Ectodomain shedding of Limbic System-Associated Membrane Protein (LSAMP) by ADAM Metallopeptidases promotes neurite outgrowth in DRG neurons.

PubMed

Sanz, Ricardo L; Ferraro, Gino B; Girouard, Marie-Pier; Fournier, Alyson E

2017-08-11

IgLONs are members of the immunoglobulin superfamily of cell adhesion proteins implicated in the process of neuronal outgrowth, cell adhesion and subdomain target recognition. IgLONs form homophilic and heterophilic complexes on the cell surface that repress or promote growth depending on the neuronal population, the developmental stage and surface repertoire of IgLON family members. In the present study, we identified a metalloproteinase-dependent mechanism necessary to promote growth in embryonic dorsal root ganglion cells (DRGs). Treatment of embryonic DRG neurons with pan-metalloproteinase inhibitors, tissue inhibitor of metalloproteinase-3, or an inhibitor of ADAM Metallopeptidase Domain 10 (ADAM10) reduces outgrowth from DRG neurons indicating that metalloproteinase activity is important for outgrowth. The IgLON family members Neurotrimin (NTM) and Limbic System-Associated Membrane Protein (LSAMP) were identified as ADAM10 substrates that are shed from the cell surface of DRG neurons. Overexpression of LSAMP and NTM suppresses outgrowth from DRG neurons. Furthermore, LSAMP loss of function decreases the outgrowth sensitivity to an ADAM10 inhibitor. Together our findings support a role for ADAM-dependent shedding of cell surface LSAMP in promoting outgrowth from DRG neurons.

Characterization of in vitro transcriptional responses of dorsal root ganglia cultured in the presence and absence of blastema cells from regenerating salamander limbs

PubMed Central

Athippozhy, Antony; Lehrberg, Jeffrey; Monaghan, James R.; Gardiner, David M.

2014-01-01

Abstract During salamander limb regeneration, nerves provide signals that induce the formation of a mass of proliferative cells called the blastema. To better understand these signals, we developed a blastema−dorsal root ganglia (DRG) co‐culture model system to test the hypothesis that nerves differentially express genes in response to cues provided by the blastema. DRG with proximal and distal nerve trunks were isolated from axolotls (Ambystoma mexicanum), cultured for 5 days, and subjected to microarray analysis. Relative to freshly isolated DRG, 1541 Affymetrix probe sets were identified as differentially expressed and many of the predicted genes are known to function in injury and neurodevelopmental responses observed for mammalian DRG. We then cultured 5‐day DRG explants for an additional 5 days with or without co‐cultured blastema cells. On day 10, we identified 27 genes whose expression in cultured DRG was significantly affected by the presence or absence of blastema cells. Overall, our study established a DRG−blastema in vitro culture system and identified candidate genes for future investigations of axon regrowth, nerve−blastema signaling, and neural regulation of limb regeneration. PMID:25750744

[Assessment of Three Risk Adjustment Systems as Predictors of the Consumption of Medicines and Medical Supplies at Polyvalent Hospitalization Units. Spain].

PubMed

Mera Flores, Ana María; Del Busto Bonifaz, Sebastián; Bernal Sobrino, José Luis

2016-09-26

The use of medicines and medical supplies is a significant component of health expenditure, linked to healthcare quality and efficient resource allocation. This study aimed to evaluate three risk adjustment systems predictive power of the consumption of medicines and medical supplies at polyvalent hospitalization units (PHU). This is an observational, retrospective study of the resources utilization in PHU between 2010 and 2013. We fitted linear regression models and evaluated their goodness of fit for three different predictors: Charlson Comorbidity Index (CCI), All Patients DRG (AP-DRG) and All Patients Refined DRG (APR-DRG) relative weights, and each one of them corrected by the length of stay. We analyzed hospitalization episodes included in the Minimum Basic Data Set (MBDS) from Fuenlabrada University Hospital. Data about the use of medicines and medical supplies were obtained from pharmacy and supply chain management information systems. Significant correlation was found between the annual consumption and the predictors considered (r=0,879 for CCI; r=0,622 for AP-DRG and r=0,514 for APR-DRG). The CCI corrected by length of stay was the variable that best fit presented (Ṝ2=0,863). The best predictive ability of CCI indicates that resource utilization depends more of the concurrent presence of additional pathology than the case mix calculated for iso-resource groups.

G-DRG Version 2009: new developments.

PubMed

Müller, Marcel L; Forschner, Andrea; Wenke, Andreas; Luger, Thomas A; Rompel, Rainer; Roeder, Norbert; Hensen, Peter

2009-04-01

The update of the G-DRG system for the year 2009 has been successfully negotiated. Like in the past years, changes are minimal and not dramatic, but they significantly enhance the quality of the DRG system. Once again, the German DRG system demonstrates its versatility and reliability for clinical reimbursement purposes. In the field of dermatology, several improvements or enhancements can be identified; the average case mix index that declined in the past years should now rise by 0.5 percent for 2009. Oncology cases are affected especially by this increase. Some refinements advanced for several years by the German Dermatologic Society (DDG) have been recognized --complex therapies like vacuum wound therapy, isolation due to multi-resistant infections and multiple primary tumors now have better cost weights. Although there still remain some minor problems like reimbursement of cost-intensive treatments, German dermatology is in summary very well prepared for the year 2009.

The exploration of medical resources utilization among inguinal hernia repair in Taiwan diagnosis-related groups.

PubMed

Yan, Yu-Hua; Kung, Chih-Ming; Chen, Yi

2017-11-09

This study centered on differences in medical costs, using the Taiwan diagnosis-related groups (Tw-DRGs) on medical resource utilization in inguinal hernia repair (IHR) in hospitals with different ownership to provide suitable reference information for hospital administrators. The 2010-2011 data for three hospitals under different ownership were extracted from the Taiwan National Health Insurance claims database. A retrospective method was applied to analyze the age, sex, length of stay, diagnosis and surgical procedure code, and the change in financial risk of medical costs in IHR cases after introduction of Tw-DRGs. The study calculated the cost using Tw-DRG payment principles, and compared it with estimated inpatient medical costs calculated using the fee-for-service policy. There were 723 IHR cases satisfying the Tw-DRGs criteria. Cost control in the medical care corporation hospital (US$764.2/case) was more efficient than that in the public hospital (US$902.7/case) or nonprofit proprietary hospital (US$817.1/case) surveyed in this study. For IHR, anesthesiologists in the public hospital preferred to use general anesthesia (86%), while those in the two other hospitals tended to administer spinal anesthesia. We also discovered the difference in anesthesia cost was high, at US$80.2/case on average. Because the Tw-DRG-based reimbursement system produces varying hospital costs, hospital administrators should establish a financial risk assessment system as early as possible to improve healthcare quality and financial management efficiency. This would then benefit the hospital, patient, and Bureau of National Health Insurance.

Isolated dorsal root ganglion neurones inhibit receptor-dependent adenylyl cyclase activity in associated glial cells

PubMed Central

Ng, KY; Yeung, BHS; Wong, YH; Wise, H

2013-01-01

Background and Purpose Hyper-nociceptive PGE2 EP4 receptors and prostacyclin (IP) receptors are present in adult rat dorsal root ganglion (DRG) neurones and glial cells in culture. The present study has investigated the cell-specific expression of two other Gs-protein coupled hyper-nociceptive receptor systems: β-adrenoceptors and calcitonin gene-related peptide (CGRP) receptors in isolated DRG cells and has examined the influence of neurone–glial cell interactions in regulating adenylyl cyclase (AC) activity. Experimental Approach Agonist-stimulated AC activity was determined in mixed DRG cell cultures from adult rats and compared with activity in DRG neurone-enriched cell cultures and pure DRG glial cell cultures. Key Results Pharmacological analysis showed the presence of Gs-coupled β2-adrenoceptors and CGRP receptors, but not β1-adrenoceptors, in all three DRG cell preparations. Agonist-stimulated AC activity was weakest in DRG neurone-enriched cell cultures. DRG neurones inhibited IP receptor-stimulated glial cell AC activity by a process dependent on both cell–cell contact and neurone-derived soluble factors, but this is unlikely to involve purine or glutamine receptor activation. Conclusions and Implications Gs-coupled hyper-nociceptive receptors are readily expressed on DRG glial cells in isolated cell cultures and the activity of CGRP, EP4 and IP receptors, but not β2-adrenoceptors, in glial cells is inhibited by DRG neurones. Studies using isolated DRG cells should be aware that hyper-nociceptive ligands may stimulate receptors on glial cells in addition to neurones, and that variable numbers of neurones and glial cells will influence absolute measures of AC activity and affect downstream functional responses. PMID:22924655

Comparative functional expression of nAChR subtypes in rodent DRG neurons.

PubMed

Smith, Nathan J; Hone, Arik J; Memon, Tosifa; Bossi, Simon; Smith, Thomas E; McIntosh, J Michael; Olivera, Baldomero M; Teichert, Russell W

2013-01-01

We investigated the functional expression of nicotinic acetylcholine receptors (nAChRs) in heterogeneous populations of dissociated rat and mouse lumbar dorsal root ganglion (DRG) neurons by calcium imaging. By this experimental approach, it is possible to investigate the functional expression of multiple receptor and ion-channel subtypes across more than 100 neuronal and glial cells simultaneously. Based on nAChR expression, DRG neurons could be divided into four subclasses: (1) neurons that express predominantly α3β4 and α6β4 nAChRs; (2) neurons that express predominantly α7 nAChRs; (3) neurons that express a combination of α3β4/α6β4 and α7 nAChRs; and (4) neurons that do not express nAChRs. In this comparative study, the same four neuronal subclasses were observed in mouse and rat DRG. However, the expression frequency differed between species: substantially more rat DRG neurons were in the first three subclasses than mouse DRG neurons, at all developmental time points tested in our study. Approximately 70-80% of rat DRG neurons expressed functional nAChRs, in contrast to only ~15-30% of mouse DRG neurons. Our study also demonstrated functional coupling between nAChRs, voltage-gated calcium channels, and mitochondrial Ca(2) (+) transport in discrete subsets of DRG neurons. In contrast to the expression of nAChRs in DRG neurons, we demonstrated that a subset of non-neuronal DRG cells expressed muscarinic acetylcholine receptors and not nAChRs. The general approach to comparative cellular neurobiology outlined in this paper has the potential to better integrate molecular and systems neuroscience by uncovering the spectrum of neuronal subclasses present in a given cell population and the functionally integrated signaling components expressed in each subclass.

Inflammatory sensitization of nociceptors depends on activation of NMDA receptors in DRG satellite cells.

PubMed

Ferrari, Luiz Fernando; Lotufo, Celina Monteiro; Araldi, Dionéia; Rodrigues, Marcos A; Macedo, Larissa P; Ferreira, Sérgio H; Parada, Carlos Amilcar

2014-12-23

The present study evaluated the role of N-methyl-D-aspartate receptors (NMDARs) expressed in the dorsal root ganglia (DRG) in the inflammatory sensitization of peripheral nociceptor terminals to mechanical stimulation. Injection of NMDA into the fifth lumbar (L5)-DRG induced hyperalgesia in the rat hind paw with a profile similar to that of intraplantar injection of prostaglandin E2 (PGE2), which was significantly attenuated by injection of the NMDAR antagonist D(-)-2-amino-5-phosphonopentanoic acid (D-AP-5) in the L5-DRG. Moreover, blockade of DRG AMPA receptors by the antagonist 6,7-dinitroquinoxaline-2,3-dione had no effect in the PGE2-induced hyperalgesia in the paw, showing specific involvement of NMDARs in this modulatory effect and suggesting that activation of NMDAR in the DRG plays an important role in the peripheral inflammatory hyperalgesia. In following experiments we observed attenuation of PGE2-induced hyperalgesia in the paw by the knockdown of NMDAR subunits NR1, NR2B, NR2D, and NR3A with antisense-oligodeoxynucleotide treatment in the DRG. Also, in vitro experiments showed that the NMDA-induced sensitization of cultured DRG neurons depends on satellite cell activation and on those same NMDAR subunits, suggesting their importance for the PGE2-induced hyperalgesia. In addition, fluorescent calcium imaging experiments in cultures of DRG cells showed induction of calcium transients by glutamate or NMDA only in satellite cells, but not in neurons. Together, the present results suggest that the mechanical inflammatory nociceptor sensitization is dependent on glutamate release at the DRG and subsequent NMDAR activation in satellite glial cells, supporting the idea that the peripheral hyperalgesia is an event modulated by a glutamatergic system in the DRG.

PGE2 released by primary sensory neurons modulates Toll-like receptor 4 activities through an EP4 receptor-dependent process.

PubMed

Tse, Kai-Hei; Chow, Kevin B S; Wise, Helen

2016-04-15

Exogenous prostaglandin E2 (PGE2) displays mixed regulatory properties with regard to inflammatory gene expression in dorsal root ganglion (DRG) cells. We show here that endogenously-produced nanomolar concentrations of PGE2, such as that generated in response to Toll-like receptor 4 (TLR4) stimulation, inhibits both cyclooxygenase-2 (COX-2) and tumour necrosis factor alpha (TNFα) mRNA expression in DRG cells in an EP4 receptor-dependent manner. DRG neurons appear to be the major source of PGE2 in the DRG and likely serve as both an autocrine and paracrine system for limiting over-activation of both DRG neurons and glial cells in response to TLR4 stimulation. Copyright © 2016 Elsevier B.V. All rights reserved.

[Evaluation of the capacity of the APR-DRG classification system to predict hospital mortality].

PubMed

De Marco, Maria Francesca; Lorenzoni, Luca; Addari, Piero; Nante, Nicola

2002-01-01

Inpatient mortality has increasingly been used as an hospital outcome measure. Comparing mortality rates across hospitals requires adjustment for patient risks before making inferences about quality of care based on patient outcomes. Therefore it is essential to dispose of well performing severity measures. The aim of this study is to evaluate the ability of the All Patient Refined DRG system to predict inpatient mortality for congestive heart failure, myocardial infarction, pneumonia and ischemic stroke. Administrative records were used in this analysis. We used two statistics methods to assess the ability of the APR-DRG to predict mortality: the area under the receiver operating characteristics curve (referred to as the c-statistic) and the Hosmer-Lemeshow test. The database for the study included 19,212 discharges for stroke, pneumonia, myocardial infarction and congestive heart failure from fifteen hospital participating in the Italian APR-DRG Project. A multivariate analysis was performed to predict mortality for each condition in study using age, sex and APR-DRG risk mortality subclass as independent variables. Inpatient mortality rate ranges from 9.7% (pneumonia) to 16.7% (stroke). Model discrimination, calculated using the c-statistic, was 0.91 for myocardial infarction, 0.68 for stroke, 0.78 for pneumonia and 0.71 for congestive heart failure. The model calibration assessed using the Hosmer-Leme-show test was quite good. The performance of the APR-DRG scheme when used on Italian hospital activity records is similar to that reported in literature and it seems to improve by adding age and sex to the model. The APR-DRG system does not completely capture the effects of these variables. In some cases, the better performance might be due to the inclusion of specific complications in the risk-of-mortality subclass assignment.

Modelling the dorsal root ganglia using human pluripotent stem cells: A platform to study peripheral neuropathies.

PubMed

Viventi, Serena; Dottori, Mirella

2018-07-01

Sensory neurons of the dorsal root ganglia (DRG) are the primary responders to stimuli inducing feelings of touch, pain, temperature, vibration, pressure and muscle tension. They consist of multiple subpopulations based on their morphology, molecular and functional properties. Our understanding of DRG sensory neurons has been predominantly driven by rodent studies and using transformed cell lines, whereas less is known about human sensory DRG neurons simply because of limited availability of human tissue. Although these previous studies have been fundamental for our understanding of the sensory system, it is imperative to profile human DRG subpopulations as it is becoming evident that human sensory neurons do not share the identical molecular and functional properties found in other species. Furthermore, there are wide range of diseases and disorders that directly/indirectly cause sensory neuronal degeneration or dysfunctionality. Having an in vitro source of human DRG sensory neurons is paramount for studying their development, unique neuronal properties and for accelerating regenerative therapies to treat sensory neuropathies. Here we review the major studies describing generation of DRG sensory neurons from human pluripotent stem cells and fibroblasts and the gaps that need to be addressed for using in vitro-generated human DRG neurons to model human DRG tissue. Copyright © 2018 Elsevier Ltd. All rights reserved.

Transfusion practice in Helsinki University Central Hospital: an analysis of diagnosis-related groups (DRG).

PubMed

Syrjälä, M T; Kytöniemi, I; Mikkolainen, K; Ranimo, J; Lauharanta, J

2001-12-01

Transfusion data combined with data automatically recorded in hospital databases provides an outstanding tool for blood utilization reporting. When the reporting is performed with an online analytical processing (OLAP) tool, real time reporting can be provided to blood subscribers. When this data is combined with a common patient classification system, Diagnosis-Related Groups (DRG), it is possible to produce statistical results, that are similar in different institutions and may provide a means for international transfusion bench-marking and cost comparison. We use a DRG classification to describe the transfusion practice in Helsinki University Central Hospital. The key indicators include the percentage of transfused patients, the number of transfused units and costs in different DRG groups, as well as transfusion rates per DRG weighted treatment episodes. Ninety-three per cent of all transfusions could be classified into different DRGs. The largest blood-using DRG group was acute adult leukaemia (DRG 473), which accounted for 10.4% of all transfusion costs. The 13 largest blood consuming DRGs accounted for half the total costs in 1998. Currently, there is a lack of an internationally accepted standardized way to report institutional or national transfusion practices. DRG-based transfusion reporting might serve as a means for transfusion benchmarking and thus aid studies of variations in transfusion practice.

Hospital services and casemix in Western Australia.

PubMed

Hendrie, Delia; Boldy, Duncan

2002-01-01

The Health Department of WA currently operates as a single integrated funder and purchaser of health services for the State. Health Service Agreements defining the level of health provision are negotiated with the various health services in WA. During the latter part of the 1990s, the funding of public hospitals for acute inpatient care moved away from a historical basis to output-based funding using a casemix approach based on Diagnosis Related Groups (DRGs). Other hospital services are still mainly purchased using historical funding levels, negotiated block funding or bedday payments, with output-based funding mechanisms under investigation. WA has developed its own approach to classifying admitted patients that recognises differences in complexity of care among episodes grouped to the same DRG. WA also has a unique cost estimation model for calculating DRG cost weights, which is based on a linear estimate of the relationship between nights of stay in hospital and the cost of hospital care for each DRG. Another emerging trend in the provision of public hospital services in WA has been the greater involvement of the private sector through the contracting of private providers to operate public hospitals. While no close examination has been undertaken of the outcomes of these changes in terms of their effect on efficiency or other relevant indicators of hospital performance, current purchasing arrangements are being reviewed following recommendations made in a report by the Health Administrative Review Committee. No decision has yet been made as to future changes to the funding policy of WA public hospitals.

Comparison of the force exerted by hippocampal and DRG growth cones.

PubMed

Amin, Ladan; Ercolini, Erika; Ban, Jelena; Torre, Vincent

2013-01-01

Mechanical properties such as force generation are fundamental for neuronal motility, development and regeneration. We used optical tweezers to compare the force exerted by growth cones (GCs) of neurons from the Peripheral Nervous System (PNS), such as Dorsal Root Ganglia (DRG) neurons, and from the Central Nervous System (CNS) such as hippocampal neurons. Developing GCs from dissociated DRG and hippocampal neurons were obtained from P1-P2 and P10-P12 rats. Comparing their morphology, we observed that the area of GCs of hippocampal neurons was 8-10 µm(2) and did not vary between P1-P2 and P10-P12 rats, but GCs of DRG neurons were larger and their area increased from P1-P2 to P10-P12 by 2-4 times. The force exerted by DRG filopodia was in the order of 1-2 pN and never exceeded 5 pN, while hippocampal filopodia exerted a larger force, often in the order of 5 pN. Hippocampal and DRG lamellipodia exerted lateral forces up to 20 pN, but lamellipodia of DRG neurons could exert a vertical force larger than that of hippocampal neurons. Force-velocity relationships (Fv) in both types of neurons had the same qualitative behaviour, consistent with a common autocatalytic model of force generation. These results indicate that molecular mechanisms of force generation of GC from CNS and PNS neurons are similar but the amplitude of generated force is influenced by their cytoskeletal properties.

Comparison of the Force Exerted by Hippocampal and DRG Growth Cones

PubMed Central

Amin, Ladan; Ercolini, Erika; Ban, Jelena; Torre, Vincent

2013-01-01

Mechanical properties such as force generation are fundamental for neuronal motility, development and regeneration. We used optical tweezers to compare the force exerted by growth cones (GCs) of neurons from the Peripheral Nervous System (PNS), such as Dorsal Root Ganglia (DRG) neurons, and from the Central Nervous System (CNS) such as hippocampal neurons. Developing GCs from dissociated DRG and hippocampal neurons were obtained from P1-P2 and P10-P12 rats. Comparing their morphology, we observed that the area of GCs of hippocampal neurons was 8-10 µm2 and did not vary between P1-P2 and P10-P12 rats, but GCs of DRG neurons were larger and their area increased from P1-P2 to P10-P12 by 2-4 times. The force exerted by DRG filopodia was in the order of 1-2 pN and never exceeded 5 pN, while hippocampal filopodia exerted a larger force, often in the order of 5 pN. Hippocampal and DRG lamellipodia exerted lateral forces up to 20 pN, but lamellipodia of DRG neurons could exert a vertical force larger than that of hippocampal neurons. Force-velocity relationships (Fv) in both types of neurons had the same qualitative behaviour, consistent with a common autocatalytic model of force generation. These results indicate that molecular mechanisms of force generation of GC from CNS and PNS neurons are similar but the amplitude of generated force is influenced by their cytoskeletal properties. PMID:23991169

Accuracy of the All Patient Refined Diagnosis Related Groups Classification System in Congenital Heart Surgery

PubMed Central

Parnell, Aimee S.; Shults, Justine; Gaynor, J. William; Leonard, Mary B.; Dai, Dingwei; Feudtner, Chris

2015-01-01

Background Administrative data is increasingly used to evaluate clinical outcomes and quality of care in pediatric congenital heart surgery (CHS) programs. Several published analyses of large pediatric administrative datasets have relied on the All Patient Refined Diagnosis Related Groups (APR-DRG, version 24) diagnostic classification system. The accuracy of this classification system for patients undergoing CHS is unclear. Methods We performed a retrospective cohort study of all 14,098 patients 0-5 years of age undergoing any of six selected congenital heart operations, ranging in complexity from isolated closure of a ventricular septal defect to single ventricle palliation, at 40 tertiary care pediatric centers in the Pediatric Health Information Systems database between 2007 and 2010. Assigned APR-DRGs (cardiac versus non-cardiac) were compared using chi-squared or Fisher's exact tests between those patients admitted during the first day of life versus later and between those receiving extracorporeal membrane oxygenation support versus not. Recursive partitioning was used to assess the greatest determinants of APR-DRG type in the model. Results Every patient admitted on day of life 1 was assigned to a non-cardiac APR-DRG (p < 0.001 for each procedure). Similarly, use of extracorporeal membrane oxygenation was highly associated with misclassification of congenital heart surgery patients into a non-cardiac APR-DRG (p < 0.001 for each procedure). Cases misclassified into a non-cardiac APR-DRG experienced a significantly increased mortality (p < 0.001). Conclusions In classifying patients undergoing congenital heart surgery, APR-DRG coding has systematic misclassifications, which may result in inaccurate reporting of CHS case volumes and mortality. PMID:24200398

Investigating DRG cost weights for hospitals in middle income countries.

PubMed

Ghaffari, Shahram; Doran, Christopher; Wilson, Andrew; Aisbett, Chris; Jackson, Terri

2009-01-01

Identifying the cost of hospital outputs, particularly acute inpatients measured by Diagnosis Related Groups (DRGs), is an important component of casemix implementation. Measuring the relative costliness of specific DRGs is useful for a wide range of policy and planning applications. Estimating the relative use of resources per DRG can be done through different costing approaches depending on availability of information and time and budget. This study aims to guide costing efforts in Iran and other countries in the region that are pursuing casemix funding, through identifying the main issues facing cost finding approaches and introducing the costing models compatible with their hospitals accounting and management structures. The results show that inadequate financial and utilisation information at the patient's level, poorly computerized 'feeder systems'; and low quality data make it impossible to estimate reliable DRGs costs through clinical costing. A cost modelling approach estimates the average cost of 2.723 million Rials (Iranian Currency) per DRG. Using standard linear regression, a coefficient of 0.14 (CI = 0.12-0.16) suggests that the average cost weight increases by 14% for every one-day increase in average length of stay (LOS).We concluded that calculation of DRG cost weights (CWs) using Australian service weights provides a sensible starting place for DRG-based hospital management; but restructuring hospital accounting systems, designing computerized feeder systems, using appropriate software, and development of national service weights that reflect local practice patterns will enhance the accuracy of DRG CWs.

[Differentiation of coding quality in orthopaedics by special, illustration-oriented case group analysis in the G-DRG System 2005].

PubMed

Schütz, U; Reichel, H; Dreinhöfer, K

2007-01-01

We introduce a grouping system for clinical practice which allows the separation of DRG coding in specific orthopaedic groups based on anatomic regions, operative procedures, therapeutic interventions and morbidity equivalent diagnosis groups. With this, a differentiated aim-oriented analysis of illustrated internal DRG data becomes possible. The group-specific difference of the coding quality between the DRG groups following primary coding by the orthopaedic surgeon and final coding by the medical controlling is analysed. In a consecutive series of 1600 patients parallel documentation and group-specific comparison of the relevant DRG parameters were carried out in every case after primary and final coding. Analysing the group-specific share in the additional CaseMix coding, the group "spine surgery" dominated, closely followed by the groups "arthroplasty" and "surgery due to infection, tumours, diabetes". Altogether, additional cost-weight-relevant coding was necessary most frequently in the latter group (84%), followed by group "spine surgery" (65%). In DRGs representing conservative orthopaedic treatment documented procedures had nearly no influence on the cost weight. The introduced system of case group analysis in internal DRG documentation can lead to the detection of specific problems in primary coding and cost-weight relevant changes of the case mix. As an instrument for internal process control in the orthopaedic field, it can serve as a communicative interface between an economically oriented classification of the hospital performance and a specific problem solution of the medical staff involved in the department management.

Risk-adjusted capitation funding models for chronic disease in Australia: alternatives to casemix funding.

PubMed

Antioch, K M; Walsh, M K

2002-01-01

Under Australian casemix funding arrangements that use Diagnosis-Related Groups (DRGs) the average price is policy based, not benchmarked. Cost weights are too low for State-wide chronic disease services. Risk-adjusted Capitation Funding Models (RACFM) are feasible alternatives. A RACFM was developed for public patients with cystic fibrosis treated by an Australian Health Maintenance Organization (AHMO). Adverse selection is of limited concern since patients pay solidarity contributions via Medicare levy with no premium contributions to the AHMO. Sponsors paying premium subsidies are the State of Victoria and the Federal Government. Cost per patient is the dependent variable in the multiple regression. Data on DRG 173 (cystic fibrosis) patients were assessed for heteroskedasticity, multicollinearity, structural stability and functional form. Stepwise linear regression excluded non-significant variables. Significant variables were 'emergency' (1276.9), 'outlier' (6377.1), 'complexity' (3043.5), 'procedures' (317.4) and the constant (4492.7) (R(2)=0.21, SE=3598.3, F=14.39, Prob<0.0001. Regression coefficients represent the additional per patient costs summed to the base payment (constant). The model explained 21% of the variance in cost per patient. The payment rate is adjusted by a best practice annual admission rate per patient. The model is a blended RACFM for in-patient, out-patient, Hospital In The Home, Fee-For-Service Federal payments for drugs and medical services; lump sum lung transplant payments and risk sharing through cost (loss) outlier payments. State and Federally funded home and palliative services are 'carved out'. The model, which has national application via Coordinated Care Trials and by Australian States for RACFMs may be instructive for Germany, which plans to use Australian DRGs for casemix funding. The capitation alternative for chronic disease can improve equity, allocative efficiency and distributional justice. The use of Diagnostic Cost Groups (DCGs) is a promising alternative classification system for capitation arrangements.

Growth Cone Biomechanics in Peripheral and Central Nervous System Neurons

NASA Astrophysics Data System (ADS)

Urbach, Jeffrey; Koch, Daniel; Rosoff, Will; Geller, Herbert

2012-02-01

The growth cone, a highly motile structure at the tip of an axon, integrates information about the local environment and modulates outgrowth and guidance, but little is known about effects of external mechanical cues and internal mechanical forces on growth-cone mediated guidance. We have investigated neurite outgrowth, traction forces and cytoskeletal substrate coupling on soft elastic substrates for dorsal root ganglion (DRG) neurons (from the peripheral nervous system) and hippocampal neurons (from the central) to see how the mechanics of the microenvironment affect different populations. We find that the biomechanics of DRG neurons are dramatically different from hippocampal, with DRG neurons displaying relatively large, steady traction forces and maximal outgrowth and forces on substrates of intermediate stiffness, while hippocampal neurons display weak, intermittent forces and limited dependence of outgrowth and forces on substrate stiffness. DRG growth cones have slower rates of retrograde actin flow and higher density of localized paxillin (a protein associated with substrate adhesion complexes) compared to hippocampal neurons, suggesting that the difference in force generation is due to stronger adhesions and therefore stronger substrate coupling in DRG growth cones.

Cost accounting models used for price-setting of health services: an international review.

PubMed

Raulinajtys-Grzybek, Monika

2014-12-01

The aim of the article was to present and compare cost accounting models which are used in the area of healthcare for pricing purposes in different countries. Cost information generated by hospitals is further used by regulatory bodies for setting or updating prices of public health services. The article presents a set of examples from different countries of the European Union, Australia and the United States and concentrates on DRG-based payment systems as they primarily use cost information for pricing. Differences between countries concern the methodology used, as well as the data collection process and the scope of the regulations on cost accounting. The article indicates that the accuracy of the calculation is only one of the factors that determine the choice of the cost accounting methodology. Important aspects are also the selection of the reference hospitals, precise and detailed regulations and the existence of complex healthcare information systems in hospitals. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

[Is DRG Coding too Important to be Left to Physicians? - Evaluation of Economic Efficiency by Health Economists in a University Medical Centre].

PubMed

Burger, F; Walgenbach, M; Göbel, P; Parbs, S; Neugebauer, E

2017-04-01

Background: We investigated and evaluated the cost effectiveness of coding by health care economists in a centre for orthopaedics and trauma surgery in Germany, by quantifying and comparing the financial efficiency of physicians with basic knowledge of the DRG-system with the results of healthcare economists with in-depth knowledge (M.Sc.). In addition, a hospital survey was performed to establish how DRG-coding is being performed and the identity of the persons involved. Material and Methods: In a prospective and controlled study, 200 in-patients were coded by a healthcare economist (study group). Prior to that, the same cases were coded by physicians with basic training in the DRG-system, who made up the control group. All cases were picked randomly and blinded without informing the physicians coding the controls, in order to avoid any Hawthorne effect. We evaluated and measured the effective weighting within the G-DRG, the DRG returns per patient, the overall DRG return, and the additional time needed. For the survey, questionnaires were sent to 1200 German hospitals. The completed questionnaire was analysed using a statistical program. Results: The return difference per patient between controls and the study group was significantly greater (2472 ± 337 €; p < 0.05); the overall return was raised by 494,500 €. The mean additional time needed was 11.32 ± 0.8 min per case, resulting in an increase in proceeds of 218 ± 38 € per minute. 2.5 % of all cases had to be devaluated by the health economist after the initial coding by the control group. Returned sheets of 60 hospitals were evaluated. The median level of DRG case reports was 1277 (2500-62,300). Coding was performed in 69 % of cases by doctors, 19 % by skilled specialists for DRG coding and in 8 % together. Overall satisfaction with the DRG was described by 61 % of respondents as good or excellent. Conclusion: Our prospective and controlled study quantifies the cost efficiency of health economists in a centre of orthopaedics and trauma surgery in Germany for the first time. We provide some initial evidence that health economists can enhance the CMI, the resulting DRG return per patient as well as the overall DRG return. Data from the survey shows that in many hospitals there is great reluctance to leave the coding to specialists only. Georg Thieme Verlag KG Stuttgart · New York.

Changing Patient Classification System for Hospital Reimbursement in Romania

PubMed Central

Radu, Ciprian-Paul; Chiriac, Delia Nona; Vladescu, Cristian

2010-01-01

Aim To evaluate the effects of the change in the diagnosis-related group (DRG) system on patient morbidity and hospital financial performance in the Romanian public health care system. Methods Three variables were assessed before and after the classification switch in July 2007: clinical outcomes, the case mix index, and hospital budgets, using the database of the National School of Public Health and Health Services Management, which contains data regularly received from hospitals reimbursed through the Romanian DRG scheme (291 in 2009). Results The lack of a Romanian system for the calculation of cost-weights imposed the necessity to use an imported system, which was criticized by some clinicians for not accurately reflecting resource consumption in Romanian hospitals. The new DRG classification system allowed a more accurate clinical classification. However, it also exposed a lack of physicians’ knowledge on diagnosing and coding procedures, which led to incorrect coding. Consequently, the reported hospital morbidity changed after the DRG switch, reflecting an increase in the national case mix index of 25% in 2009 (compared with 2007). Since hospitals received the same reimbursement over the first two years after the classification switch, the new DRG system led them sometimes to change patients' diagnoses in order to receive more funding. Conclusion Lack of oversight of hospital coding and reporting to the national reimbursement scheme allowed the increase in the case mix index. The complexity of the new classification system requires more resources (human and financial), better monitoring and evaluation, and improved legislation in order to achieve better hospital resource allocation and more efficient patient care. PMID:20564769

Changing patient classification system for hospital reimbursement in Romania.

PubMed

Radu, Ciprian-Paul; Chiriac, Delia Nona; Vladescu, Cristian

2010-06-01

To evaluate the effects of the change in the diagnosis-related group (DRG) system on patient morbidity and hospital financial performance in the Romanian public health care system. Three variables were assessed before and after the classification switch in July 2007: clinical outcomes, the case mix index, and hospital budgets, using the database of the National School of Public Health and Health Services Management, which contains data regularly received from hospitals reimbursed through the Romanian DRG scheme (291 in 2009). The lack of a Romanian system for the calculation of cost-weights imposed the necessity to use an imported system, which was criticized by some clinicians for not accurately reflecting resource consumption in Romanian hospitals. The new DRG classification system allowed a more accurate clinical classification. However, it also exposed a lack of physicians' knowledge on diagnosing and coding procedures, which led to incorrect coding. Consequently, the reported hospital morbidity changed after the DRG switch, reflecting an increase in the national case-mix index of 25% in 2009 (compared with 2007). Since hospitals received the same reimbursement over the first two years after the classification switch, the new DRG system led them sometimes to change patients' diagnoses in order to receive more funding. Lack of oversight of hospital coding and reporting to the national reimbursement scheme allowed the increase in the case-mix index. The complexity of the new classification system requires more resources (human and financial), better monitoring and evaluation, and improved legislation in order to achieve better hospital resource allocation and more efficient patient care.

Cost accounting to determine prices: how well do prices reflect costs in the German DRG-system?

PubMed

Schreyögg, Jonas; Tiemann, Oliver; Busse, Reinhard

2006-08-01

Germany has recently introduced a system of Diagnosis Related Groups (DRGs) to engender more appropriate resource allocation. The following article describes the German DRG-system and the methodologies used to determine prices. It analyses the extent to which prices, or calculated cost weights, reflect the actual costs incurred by hospitals for their respective services. We reveal that a "compression" of DRG cost weights occurs, and that the data sample used to calculate cost weights is lacking in terms of its representativeness. Although cost data accuracy has improved over the last few years there are still a number of challenges that need to be addressed.

[Ethical insolvency?].

PubMed

von Weizsäcker, F; Maio, G

2010-04-01

The current DRG system has not only changed the economic structure of clinical medicine but also has profound effects on its original mission. In the present paper we discuss the fundamental limits of the DRG system and make a case for placing more emphasis on time and communication in health care. Georg Thieme Verlag KG Stuttgart. New York.

Accuracy of the all patient refined diagnosis related groups classification system in congenital heart surgery.

PubMed

Parnell, Aimee S; Shults, Justine; Gaynor, J William; Leonard, Mary B; Dai, Dingwei; Feudtner, Chris

2014-02-01

Administrative data are increasingly used to evaluate clinical outcomes and quality of care in pediatric congenital heart surgery (CHS) programs. Several published analyses of large pediatric administrative data sets have relied on the All Patient Refined Diagnosis Related Groups (APR-DRG, version 24) diagnostic classification system. The accuracy of this classification system for patients undergoing CHS is unclear. We performed a retrospective cohort study of all 14,098 patients 0 to 5 years of age undergoing any of six selected congenital heart operations, ranging in complexity from isolated closure of a ventricular septal defect to single-ventricle palliation, at 40 tertiary-care pediatric centers in the Pediatric Health Information Systems database between 2007 and 2010. Assigned APR-DRGs (cardiac versus noncardiac) were compared using χ2 or Fisher's exact tests between those patients admitted during the first day of life versus later and between those receiving extracorporeal membrane oxygenation support versus those not. Recursive partitioning was used to assess the greatest determinants of APR-DRG type in the model. Every patient admitted on day 1 of life was assigned to a noncardiac APR-DRG (p<0.001 for each procedure). Similarly, use of extracorporeal membrane oxygenation was highly associated with misclassification of CHS patients into a noncardiac APR-DRG (p<0.001 for each procedure). Cases misclassified into a noncardiac APR-DRG experienced a significantly increased mortality (p<0.001). In classifying patients undergoing CHS, APR-DRG coding has systematic misclassifications, which may result in inaccurate reporting of CHS case volumes and mortality. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Costs of disposable material in the operating room do not show high correlation with surgical time: Implications for hospital payment.

PubMed

Delo, Caroline; Leclercq, Pol; Martins, Dimitri; Pirson, Magali

2015-08-01

The objectives of this study are to analyze the variation of the surgical time and of disposable costs per surgical procedure and to analyze the association between disposable costs and the surgical time. The registration of data was done in an operating room of a 419 bed general hospital, over a period of three months (n = 1556 surgical procedures). Disposable material per procedure used was recorded through a barcode scanning method. The average cost (standard deviation) of disposable material is €183.66 (€183.44). The mean surgical time (standard deviation) is 96 min (63). Results have shown that the homogeneity of operating time and DM costs was quite good per surgical procedure. The correlation between the surgical time and DM costs is not high (r = 0.65). In a context of Diagnosis Related Group (DRG) based hospital payment, it is important that costs information systems are able to precisely calculate costs per case. Our results show that the correlation between surgical time and costs of disposable materials is not good. Therefore, empirical data or itemized lists should be used instead of surgical time as a cost driver for the allocation of costs of disposable materials to patients. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

[Neonatal septicemia in the G-DRG system].

PubMed

Mohrmann, M; Hentschel, R; Böhler, T; Dirschedl, P

2006-12-01

The introduction of Diagnosis Related Groups in Germany (G-DRG) has brought forward the obligation for physicians to take into account an intricate system of medical, economical and legal implementations. Mistakes in the process of encoding the principal diagnosis or procedures may have financial consequences. Problems to determine the correct ICD-code will be most prominent for diseases with poorly defined or even inconsistent diagnostic criteria as is the case for neonatal septicemia. We decided to evaluate whether the introduction of G-DRG resulted in a change of frequency of the diagnosis "neonatal septicemia". We analysed data derived from the quality assurance program "Neonatalerhebung" in the state of Baden-Württemberg during the years of 2001 through 2004, i. e., 2 years before and 2 years during the introduction of G-DRG. During this period an annual number of 12,316 up to 13,172 newborns were admitted to the participating hospitals. The mean number of diagnoses per patient increased from 2.2 to 3.8. The frequency of the diagnosis of septicemia remained constant. The percentage of newborns receiving antibiotic therapy did not change. The ratio of cases with "septicemia yes" over "antibiotics yes" did not change. Although it is difficult to determine the diagnosis of neonatal septicemia and in spite of the economic implications of this diagnosis, no change in the frequency of this diagnosis occurred during the introduction of DRG. Assuming that the participating hospitals used an identical database for the quality assurance program "Neonatalerhebung" and for accounting, we conclude that the DRG system is stable with respect to neonatal septicemia.

Metabolic changes of cultured DRG neurons induced by adenosine using confocal microscopy imaging

NASA Astrophysics Data System (ADS)

Zheng, Liqin; Huang, Yimei; Chen, Jiangxu; Wang, Yuhua; Yang, Hongqin; Zhang, Yanding; Xie, Shusen

2012-12-01

Adenosine exerts multiple effects on pain transmission in the peripheral nervous system. This study was performed to use confocal microscopy to evaluate whether adenosine could affect dorsal root ganglia (DRG) neurons in vitro and test which adenosine receptor mediates the effect of adenosine on DRG neurons. After adding adenosine with different concentration, we compared the metabolic changes by the real time imaging of calcium and mitochondria membrane potential using confocal microscopy. The results showed that the effect of 500 μM adenosine on the metabolic changes of DRG neurons was more significant than others. Furthermore, four different adenosine receptor antagonists were used to study which receptor mediated the influences of adenosine on the cultured DRG neurons. All adenosine receptor antagonists especially A1 receptor antagonist (DPCPX) had effect on the Ca2+ and mitochondria membrane potential dynamics of DRG neurons. The above studies demonstrated that the effect of adenosine which may be involved in the signal transmission on the sensory neurons was dose-dependent, and all the four adenosine receptors especially the A1R may mediate the transmission.

Improving patient-level costing in the English and the German 'DRG' system.

PubMed

Vogl, Matthias

2013-03-01

The purpose of this paper is to develop ways to improve patient-level cost apportioning (PLCA) in the English and German inpatient 'DRG' cost accounting systems, to support regulators in improving costing schemes, and to give clinicians and hospital management sophisticated tools to measure and link their management. The paper analyzes and evaluates the PLCA step in the cost accounting schemes of both countries according to the impact on the key aspects of DRG introduction: transparency and efficiency. The goal is to generate a best available PLCA standard with enhanced accuracy and managerial relevance, the main requirements of cost accounting. A best available PLCA standard in 'DRG' cost accounting uses: (1) the cost-matrix from the German system; (2) a third axis in this matrix, representing service-lines or clinical pathways; (3) a scoring system for key cost drivers with the long-term objective of time-driven activity-based costing and (4) a point of delivery separation. Both systems have elements that the other system can learn from. By combining their strengths, regulators are supported in enhancing PLCA systems, improving the accuracy of national reimbursement and the managerial relevance of inpatient cost accounting systems, in order to reduce costs in health care. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

[Cost-benefit analysis of cranial computed tomography in mild traumatic brain injury--appropriate depiction within the G-DRG system?].

PubMed

Garving, C; Weber, C D; Poßelt, S; Pishnamaz, M; Pape, H C; Dienstknecht, T

2014-06-01

The treatment of patients with mild head injury is related to a continuous lack of finances. The current investigation summarises radiological costs of patients from a level I trauma centre and discusses the indication for CT scanning within the G-DRG system. The study includes all patients who underwent a CCT scan in 2011. Diagnosis, length of stay and cost data were recorded for every patient. Finally, frequent diagnosis groups were summarised to clusters (Basis-DRG/MDC 21A). A total of 380 patients was treated. Within the largest group (G-DRG B80Z) the costs for a CCT already took up one quarter of the total proceedings. In combination with the high cost for monitoring patients with mild head injuries this causes an ongoing lack of finances. In spite of the often necessary CCT investigation in mild head injuries, the earnings do not cover the costs of the patients. To improve the situation clear guidelines for CCT scanning should be provided and the reimbursement in particular in the diagnosis group of the G-DRG B80Z has to be improved. Georg Thieme Verlag KG Stuttgart · New York.

The intriguing nature of dorsal root ganglion neurons: linking structure with polarity and function.

PubMed

Nascimento, Ana Isabel; Mar, Fernando Milhazes; Sousa, Mónica Mendes

2018-05-02

Dorsal root ganglion (DRG) neurons are the first neurons of the sensory pathway. They are activated by a variety of sensory stimuli that are then transmitted to the central nervous system. An important feature of DRG neurons is their unique morphology where a single process -the stem axon- bifurcates into a peripheral and a central axonal branch, with different functions and cellular properties. Distinctive structural aspects of the two DRG neuron branches may have important implications for their function in health and disease. However, the link between DRG axonal branch structure, polarity and function has been largely neglected in the field, and relevant information is rather scattered across the literature. In particular, ultrastructural differences between the two axonal branches are likely to account for the higher transport and regenerative ability of the peripheral DRG neuron axon when compared to the central one. Nevertheless, the cell intrinsic factors contributing to this central-peripheral asymmetry are still unknown. Here we critically review the factors that may underlie the functional asymmetry between the peripheral and central DRG axonal branches. Also, we discuss the hypothesis that DRG neurons may assemble a structure resembling the axon initial segment that may be responsible, at least in part, for their polarity and electrophysiological features. Ultimately, we suggest that the clarification of the axonal ultrastructure of DRG neurons using state-of-the-art techniques will be crucial to understand the physiology of this peculiar cell type. Copyright © 2018. Published by Elsevier Ltd.

Impact of DRG billing system on health budget consumption in percutaneous treatment of mitral valve regurgitation in heart failure.

PubMed

Palmieri, Vittorio; Baldi, Cesare; Di Blasi, Paola E; Citro, Rodolfo; Di Lorenzo, Emilio; Bellino, Elisabetta; Preziuso, Feliciano; Ranaudo, Carlo; Sauro, Rosario; Rosato, Giuseppe

2015-02-01

Percutaneous correction of mitral regurgitation (MR) by MitraClip (Abbot Vascular, Abbot Park, Illinois, USA) trans-catheter procedure (MTP) may represent a treatment for an unmet need in heart failure (HF), but with a largely unclear economic impact. This study estimated the economic impact of the MTP in common practice using the disease-related group (DRG) billing system, duration and average cost per day of hospitalization as main drivers. Life expectancy was estimated based on the Seattle Heart Failure Model. Quality-of-life was derived by standard questionnaires to compute quality-adjusted year-life costs. Over 5535 discharges between 2012-2013, HF as DRG 127 was the main diagnosis in 20%, yielding a reimbursement of €3052.00/case; among the DRG 127, MR by ICD-9 coding was found in 12%. Duration of hospitalization was longer for DRG 127 with than without MR (9 vs 8 days, p < 0.05). HF in-hospital management generated most frequently deficit, in particular in the presence of MR, due to the high costs of hospitalization, higher than reimbursement. MTP to treat MR allowed DRG 104-related reimbursement of €24,675.00. In a cohort of 34 HF patients treated for MR by MTP, the global budget consumption was 2-fold higher compared to that simulated for those cases medically managed at 2-year follow-up. Extrapolated cost per quality-adjusted-life-years (QALY) for MTP at year-2 follow-up was ∼ €16,300. Based on DRG and hospitalization costing estimates, MTP might be cost-effective in selected HF patients with MR suitable for such a specific treatment, granted that those patients have a clinical profile predicting high likelihood of post-procedural clinical stability in sufficiently long follow-up.

Immunization Elicits Antigen-Specific Antibody Sequestration in Dorsal Root Ganglia Sensory Neurons

PubMed Central

Gunasekaran, Manojkumar; Chatterjee, Prodyot K.; Shih, Andrew; Imperato, Gavin H.; Addorisio, Meghan; Kumar, Gopal; Lee, Annette; Graf, John F.; Meyer, Dan; Marino, Michael; Puleo, Christopher; Ashe, Jeffrey; Cox, Maureen A.; Mak, Tak W.; Bouton, Chad; Sherry, Barbara; Diamond, Betty; Andersson, Ulf; Coleman, Thomas R.; Metz, Christine N.; Tracey, Kevin J.; Chavan, Sangeeta S.

2018-01-01

The immune and nervous systems are two major organ systems responsible for host defense and memory. Both systems achieve memory and learning that can be retained, retrieved, and utilized for decades. Here, we report the surprising discovery that peripheral sensory neurons of the dorsal root ganglia (DRGs) of immunized mice contain antigen-specific antibodies. Using a combination of rigorous molecular genetic analyses, transgenic mice, and adoptive transfer experiments, we demonstrate that DRGs do not synthesize these antigen-specific antibodies, but rather sequester primarily IgG1 subtype antibodies. As revealed by RNA-seq and targeted quantitative PCR (qPCR), dorsal root ganglion (DRG) sensory neurons harvested from either naïve or immunized mice lack enzymes (i.e., RAG1, RAG2, AID, or UNG) required for generating antibody diversity and, therefore, cannot make antibodies. Additionally, transgenic mice that express a reporter fluorescent protein under the control of Igγ1 constant region fail to express Ighg1 transcripts in DRG sensory neurons. Furthermore, neural sequestration of antibodies occurs in mice rendered deficient in neuronal Rag2, but antibody sequestration is not observed in DRG sensory neurons isolated from mice that lack mature B cells [e.g., Rag1 knock out (KO) or μMT mice]. Finally, adoptive transfer of Rag1-deficient bone marrow (BM) into wild-type (WT) mice or WT BM into Rag1 KO mice revealed that antibody sequestration was observed in DRG sensory neurons of chimeric mice with WT BM but not with Rag1-deficient BM. Together, these results indicate that DRG sensory neurons sequester and retain antigen-specific antibodies released by antibody-secreting plasma cells. Coupling this work with previous studies implicating DRG sensory neurons in regulating antigen trafficking during immunization raises the interesting possibility that the nervous system collaborates with the immune system to regulate antigen-mediated responses. PMID:29755449

Characterization of Na+ and Ca2+ Channels in Zebrafish Dorsal Root Ganglion Neurons

PubMed Central

Won, Yu-Jin; Ono, Fumihito; Ikeda, Stephen R.

2012-01-01

Background Dorsal root ganglia (DRG) somata from rodents have provided an excellent model system to study ion channel properties and modulation using electrophysiological investigation. As in other vertebrates, zebrafish (Danio rerio) DRG are organized segmentally and possess peripheral axons that bifurcate into each body segment. However, the electrical properties of zebrafish DRG sensory neurons, as compared with their mammalian counterparts, are relatively unexplored because a preparation suitable for electrophysiological studies has not been available. Methodology/Principal Findings We show enzymatically dissociated DRG neurons from juvenile zebrafish expressing Isl2b-promoter driven EGFP were easily identified with fluorescence microscopy and amenable to conventional whole-cell patch-clamp studies. Two kinetically distinct TTX-sensitive Na+ currents (rapidly- and slowly-inactivating) were discovered. Rapidly-inactivating INa were preferentially expressed in relatively large neurons, while slowly-inactivating INa was more prevalent in smaller DRG neurons. RT-PCR analysis suggests zscn1aa/ab, zscn8aa/ab, zscn4ab and zscn5Laa are possible candidates for these INa components. Voltage-gated Ca2+ currents (ICa) were primarily (87%) comprised of a high-voltage activated component arising from ω-conotoxin GVIA-sensitive CaV2.2 (N-type) Ca2+ channels. A few DRG neurons (8%) displayed a miniscule low-voltage-activated component. ICa in zebrafish DRG neurons were modulated by neurotransmitters via either voltage-dependent or -independent G-protein signaling pathway with large cell-to-cell response variability. Conclusions/Significance Our present results indicate that, as in higher vertebrates, zebrafish DRG neurons are heterogeneous being composed of functionally distinct subpopulations that may correlate with different sensory modalities. These findings provide the first comparison of zebrafish and rodent DRG neuron electrical properties and thus provide a basis for future studies. PMID:22880050

The use of DRG for identifying clinical trials centers with high recruitment potential: a feasability study.

PubMed

Aegerter, Philippe; Bendersky, Noelle; Tran, Thi-Chien; Ropers, Jacques; Taright, Namik; Chatellier, Gilles

2014-01-01

Recruitment of large samples of patients is crucial for evidence level and efficacy of clinical trials (CT). Clinical Trial Recruitment Support Systems (CTRSS) used to estimate patient recruitment are generally specific to Hospital Information Systems and few were evaluated on a large number of trials. Our aim was to assess, on a large number of CT, the usefulness of commonly available data as Diagnosis Related Groups (DRG) databases in order to estimate potential recruitment. We used the DRG database of a large French multicenter medical institution (1.2 million inpatient stays and 400 new trials each year). Eligibility criteria of protocols were broken down into in atomic entities (diagnosis, procedures, treatments...) then translated into codes and operators recorded in a standardized form. A program parsed the forms and generated requests on the DRG database. A large majority of selection criteria could be coded and final estimations of number of eligible patients were close to observed ones (median difference = 25). Such a system could be part of the feasability evaluation and center selection process before the start of the clinical trial.

CX3CL1-mediated macrophage activation contributed to paclitaxel-induced DRG neuronal apoptosis and painful peripheral neuropathy.

PubMed

Huang, Zhen-Zhen; Li, Dai; Liu, Cui-Cui; Cui, Yu; Zhu, He-Quan; Zhang, Wen-Wen; Li, Yong-Yong; Xin, Wen-Jun

2014-08-01

Painful peripheral neuropathy is a dose-limiting side effect of paclitaxel therapy, which hampers the optimal clinical management of chemotherapy in cancer patients. Currently the underlying mechanisms remain largely unknown. Here we showed that the clinically relevant dose of paclitaxel (3×8mg/kg, cumulative dose 24mg/kg) induced significant upregulation of the chemokine CX3CL1 in the A-fiber primary sensory neurons in vivo and in vitro and infiltration of macrophages into the dorsal root ganglion (DRG) in rats. Paclitaxel treatment also increased cleaved caspase-3 expression, induced the loss of primary afferent terminal fibers and decreased sciatic-evoked A-fiber responses in the spinal dorsal horn, indicating DRG neuronal apoptosis induced by paclitaxel. In addition, the paclitaxel-induced DRG neuronal apoptosis occurred exclusively in the presence of macrophage in vitro study. Intrathecal or systemic injection of CX3CL1 neutralizing antibody blocked paclitaxel-induced macrophage recruitment and neuronal apoptosis in the DRG, and also attenuated paclitaxel-induced allodynia. Furthermore, depletion of macrophage by systemic administration of clodronate inhibited paclitaxel-induced allodynia. Blocking CX3CL1 decreased activation of p38 MAPK in the macrophage, and inhibition of p38 MAPK activity blocked the neuronal apoptosis and development of mechanical allodynia induced by paclitaxel. These findings provide novel evidence that CX3CL1-recruited macrophage contributed to paclitaxel-induced DRG neuronal apoptosis and painful peripheral neuropathy. Copyright © 2014 Elsevier Inc. All rights reserved.

Differing patterns of neurotrophin-receptor expressing neurons allow distinction of the transient Frorieps' ganglia from normal DRG before morphological differences appear.

PubMed

Avivi, Camila; Goldstein, Ronald S

2003-10-10

The Frorieps' ganglia are dorsal root ganglia (DRG) that form and then degenerate during normal embryonic development of amniotes. Their degeneration or survival has been shown to be modulated by modifying expression of Hox-family and other genes involved in pattern formation, and by the mesodermal microenvironment of the cranial somites in which they develop. In ovo application of the neurotrophin NGF partially rescues DRG2 from degeneration. To further examine the potential role of neurotrophins in the life cycle of Frorieps' DRG we have now quantified the numbers of neurons expressing neurotrophin receptors trkA and trkC in avian Frorieps' ganglia (DRG2) and normal cervical DRG (DRG5). We have found that the Frorieps' DRG are different from normal DRG in terms of the numbers of neurons expressing these receptors. trkC-expressing neurons are generally lacking in DRG2, this is the earliest (St 18, E2.5) described difference between DRG2 and normal DRG, preceding morphological differences between these ganglia that appear at St 20. The difference between DRG2 and DRG5 in terms of numbers of trkA-expressing neurons is evident only at later embryonic stages, where DRG2 contains a higher proportion of trkA neurons than normal cervical DRG. The few trkC+ neurons present late in DRG2 development are not concentrated in the VL portion of the ganglion, the zone where trkC+ neurons are generally found in normal DRG. We also find that DRG2 neurons are smaller than those of normal DRG, this is true for both trkA+ and trkC+ populations. These data together therefore suggest that the neurons that survive in the Frorieps' ganglia at later stages belong almost exclusively to the trkA-expressing DM class DRG neurons. We further find that the differences in the populations of trkA/trkC between DRG2 and DRG5 result from signals from the mesodermal microenvironment, since DRG arising in cranial somites transplanted caudally contain few trkC+ neurons and a higher proportion of trkA+ cells than contralateral controls.

Neuron-glial communication mediated by TNF-α and glial activation in dorsal root ganglia in visceral inflammatory hypersensitivity.

PubMed

Song, Dan-dan; Li, Yong; Tang, Dong; Huang, Li-ya; Yuan, Yao-zong

2014-05-01

Communication between neurons and glia in the dorsal root ganglia (DRG) and the central nervous system is critical for nociception. Both glial activation and proinflammatory cytokine induction underlie this communication. We investigated whether satellite glial cell (SGC) and tumor necrosis factor-α (TNF-α) activation in DRG participates in a 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced rat model of visceral hyperalgesia. In TNBS-treated rats, TNF-α expression increased in DRG and was colocalized to SGCs enveloping a given neuron. These SGCs were activated as visualized under electron microscopy: they had more elongated processes projecting into the connective tissue space and more gap junctions. When nerves attached to DRG (L6-S1) were stimulated with a series of electrical stimulations, TNF-α were released from DRG in TNBS-treated animals compared with controls. Using a current clamp, we noted that exogenous TNF-α (2.5 ng/ml) increased DRG neuron activity, and visceral pain behavioral responses were reversed by intrathecal administration of anti-TNF-α (10 μg·kg(-1)·day(-1)). Based on our findings, TNF-α and SGC activation in neuron-glial communication are critical in inflammatory visceral hyperalgesia.

DRG Spinal Cord Stimulation as Solution for Patients With Severe Pain Due to Anterior Cutaneous Nerve Entrapment Syndrome: A Case Series.

PubMed

Mol, Frédérique Mathilde Ulrike; Roumen, Rudi M H

2018-04-01

Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) is a debilitating neuropathic pain condition. A small portion of patients do not respond to any currently available treatment modalities. These patients, often young women, might benefit from targeted spinal cord stimulation of the dorsal root ganglion (DRG). This retrospective case series describes five ACNES patients who were referred from a Dutch dedicated tertiary referral center to collaborating sites with extensive experience in DRG stimulation to be implanted with a DRG Axium System (St. Jude/Abbott, IL, USA) in the period of 2013-2016. Numeric pain rating scores at routine 6- and 12-month follow-up visits were analyzed. Three patients experienced >50% pain reduction at 12 months follow-up. Four patients experienced device-related complications, such as lead dislocation, lead breakage, pain at the battery site, and overstimulation. This case series suggests DRG spinal cord stimulation can be safe and effective for some patients with persistent pain due to ACNES. © 2017 International Neuromodulation Society.

Diffraction radiation generators

NASA Astrophysics Data System (ADS)

Shestopalov, Viktor P.; Vertii, Aleksei A.; Ermak, Gennadii P.; Skrynnik, Boris K.; Khlopov, Grigorii I.; Tsvyk, Aleksei I.

Research in the field of diffraction radiation generators (DRG) conducted at the Radio Physics and electronics Institute of the Ukranian Academy of Sciences over the past 25 years is reviewed. The effect of diffraction radiation is analyzed in detail, and various operating regimes of DRGs are discussed. The discussion then focuses on the principal requirements for the design of packaged DRGs and their principal parameters. Finally, applications of DRGs in various fields of science and technology are reviewed, including such applications as DRG spectroscopy, diagnostics of plasma, biological specimens, and vibration, and DRG radar systems.

[OR minute myth : Guidelines for calculation of DRG revenues per OR minute].

PubMed

Waeschle, R M; Hinz, J; Bleeker, F; Sliwa, B; Popov, A; Schmidt, C E; Bauer, M

2016-02-01

The economic situation in German Hospitals is tense and needs the implementation of differentiated controlling instruments. Accordingly, parameters of revenue development of different organizational units within a hospital are needed. This is particularly necessary in the revenue and cost-intensive operating theater field. So far there are only barely established productivity data for the control of operating room (OR) revenues during the year available. This article describes a valid method for the calculation of case-related revenues per OR minute conform to the diagnosis-related groups (DRG).For this purpose the relevant datasets from the OR information system and the § 21 productivity report (DRG grouping) of the University Medical Center Göttingen were combined. The revenues defined in the DRG browser of the Institute for Hospital Reimbursement (InEK) were assigned to the corresponding process times--incision-suture time (SNZ), operative preparation time and anesthesiology time--according to the InEK system. All full time stationary DRG cases treated within the OR were included and differentiated according to the surgical department responsible. The cost centers "OR section" and "anesthesia" were isolated to calculate the revenues of the operating theater. SNZ clusters and cost type groups were formed to demonstrate their impact on the revenues per OR minute. A surgical personal simultaneity factor (GZF) was calculated by division of the revenues for surgeons and anesthesiologists. This factor resembles the maximum DRG financed personnel deployment for surgeons in German hospitals.The revenue per OR minute including all cost types and DRG was 16.63 €/min. The revenues ranged from 10.45 to 24.34 €/min depending on the surgical field. The revenues were stable when SNZ clusters were analyzed. The differentiation of cost type groups revealed a revenue reduction especially after exclusion of revenues for implants and infrastructure. The calculated GZF over all surgical departments was 2.2 (range 1.9-3.6). A calculation of this factor at the DRG level can give economically relevant information about the case-related personnel deployment.This analysis shows for the first time the DRG-conform calculation of revenues per OR minute. There is a strong dependency on the considered cost type and the performing surgical field. Repetitive analyses are necessary due to the lack of reference values and are a suitable tool to monitor the revenue development after measures for process optimization. Comparative analyses within different surgical fields on this data base should be avoided. The demonstrated method can be used as a guideline for other hospitals to calculate the DRG revenues within the OR. This enables pursuing cost-effectiveness analysis by comparing these revenues with cost data from the cost unit accounting at a DRG or case level.

Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery.

PubMed

Nunley, Pierce D; Mundis, Gregory M; Fessler, Richard G; Park, Paul; Zavatsky, Joseph M; Uribe, Juan S; Eastlack, Robert K; Chou, Dean; Wang, Michael Y; Anand, Neel; Frank, Kelly A; Stone, Marcus B; Kanter, Adam S; Shaffrey, Christopher I; Mummaneni, Praveen V

2017-12-01

OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.

Nf2-Yap signaling controls the expansion of DRG progenitors and glia during DRG development

PubMed Central

Serinagaoglu, Yelda; Paré, Joshua; Giovannini, Marco; Cao, Xinwei

2014-01-01

Molecular mechanisms governing the maintenance and proliferation of dorsal root ganglia (DRG) progenitors are largely unknown. Here we reveal that the Hippo pathway regulates the expansion of DRG progenitors and glia during mammalian DRG development. The key effectors of this pathway, transcriptional coactivators Yap and Taz, are expressed in DRG progenitors and glia during DRG development but are at least partially inhibited from activating transcription. Aberrant YAP activation leads to overexpansion of DRG progenitor and glial populations. We further show that the Neurofibromatosis 2 (Nf2) tumor suppressor inhibits Yap during DRG development. Loss of Nf2 leads to similar phenotypes as does YAP hyperactivation, and deleting Yap suppresses these phenotypes. Our study demonstrates that Nf2-Yap signaling plays important roles in controlling the expansion of DRG progenitors and glia during DRG development. PMID:25433207

[In-patient (early) rehabilitation].

PubMed

Wallesch, Claus-W; Lautenschläger, Sindy

2017-04-01

It is difficult to develop the financing and hospital provision of interventions for early rehabilitation within the diagnosis-related group (DRG) system. In addition to a range of partially rehabilitative complex interventions, the system recognizes three main forms of early rehabilitative interventions: geriatric, neurological/neurosurgical, and interdisciplinary and others. In this article, the appropriate definitions and cost-effectiveness of these procedures are analyzed and compared. The early rehabilitative interventions are characterized by constant cooperation in the therapeutic team, especially neurological early rehabilitation through the incorporation of nursing as a therapeutic profession. Whereas geriatric and neurological early rehabilitation are reflected in the DRG system, the former provided in many general hospitals and the latter mainly in specialized institutions, interdisciplinary early rehabilitation has only occasionally been represented in the DRG system so far. If all acute in-patients who require early rehabilitation should receive such an intervention, an additional fee must be implemented for this this interdisciplinary service.

Nf2-Yap signaling controls the expansion of DRG progenitors and glia during DRG development.

PubMed

Serinagaoglu, Yelda; Paré, Joshua; Giovannini, Marco; Cao, Xinwei

2015-02-01

Molecular mechanisms governing the maintenance and proliferation of dorsal root ganglia (DRG) progenitors are largely unknown. Here we reveal that the Hippo pathway regulates the expansion of DRG progenitors and glia during mammalian DRG development. The key effectors of this pathway, transcriptional coactivators Yap and Taz, are expressed in DRG progenitors and glia during DRG development but are at least partially inhibited from activating transcription. Aberrant YAP activation leads to overexpansion of DRG progenitor and glial populations. We further show that the Neurofibromatosis 2 (Nf2) tumor suppressor inhibits Yap during DRG development. Loss of Nf2 leads to similar phenotypes as does YAP hyperactivation, and deleting Yap suppresses these phenotypes. Our study demonstrates that Nf2-Yap signaling plays important roles in controlling the expansion of DRG progenitors and glia during DRG development. Copyright © 2014 Elsevier Inc. All rights reserved.

[Ten years of early complex geriatric rehabilitation therapy in the DRG system].

PubMed

Kolb, G; Breuninger, K; Gronemeyer, S; van den Heuvel, D; Lübke, N; Lüttje, D; Wittrich, A; Wolff, J

2014-01-01

Geriatric medicine, as a specialized form of treatment for the elderly, is gaining in importance due to demographic changes. Especially important for geriatric medicine is combining acute care with the need to maintain functionality and participation. This includes prevention of dependency on structured care or chronic disability and handicap by means of rehabilitation. Ten years ago, the German DRG system tried to incorporate procedures (e.g., "early rehabilitation in geriatric medicine") in the hospital reimbursement system. OPS 8-550.x, defined by structural quality, days of treatment, and number of therapeutic interventions, triggers 17 different geriatric DRGs, covering most of the fields of medicine. OPS 8-550.x had been revised continuously to give a clear structure to quality aspects of geriatric procedures. However, OPS 8-550.x is based on proven need of in-hospital treatment. In the last 10 years, no such definition has been produced taking aspects of the German hospital system into account as well as aspects of transparency and benefit in everyday work. The German DRG system covers just basic reimbursement aspects of geriatric medicine quite well; however, a practicable and patient-oriented definition of "hospital necessity" is still lacking, but is absolutely essential for proper compensation. A further problem concerning geriatric medicine reimbursement in the DRG system is due to the different structures of providing geriatric in-hospital care throughout Germany.

Impact of the Sensory Neurons on Melanoma Growth In Vivo

PubMed Central

Tapias, Victor; Watkins, Simon C.; Ma, Yang; Shurin, Michael R.; Shurin, Galina V.

2016-01-01

Nerve endings are often identified within solid tumors, but their impact on the tumor growth and progression remains poorly understood. Emerging data suggests that the central nervous system may affect cancer development and spreading via the hypothalamic-pituitary-adrenal axis and autonomous nervous system. However, the role of the afferent sensory neurons in tumor growth is unclear, except some reports on perineural invasion in prostate and pancreatic cancer and cancer-related pain syndrome. Here, we provide the results of primary testing of the concept that the interaction between melanoma cells and sensory neurons may induce the formation of tumor-supporting microenvironment via attraction of immune regulatory cells by the tumor-activated dorsal root ganglion (DRG) neurons. We report that despite DRG cells not directly up-regulating proliferation of melanoma cells in vitro, presence of DRG neurons allows tumors to grow significantly faster in vivo. This effect has been associated with increased production of chemokines by tumor-activated DRG neurons and attraction of myeloid-derived suppressor cells both in vitro and in vivo. These initial proof-of-concept results justify further investigations of the sensory (afferent) nervous system in the context of tumorigenesis and the local protumorigenic immunoenvironment. PMID:27227315

Do diagnosis-related groups appropriately explain variations in costs and length of stay of hip replacement? A comparative assessment of DRG systems across 10 European countries.

PubMed

Geissler, Alexander; Scheller-Kreinsen, David; Quentin, Wilm

2012-08-01

This paper assesses the variations in costs and length of stay for hip replacement cases in Austria, England, Estonia, Finland, France, Germany, Ireland, Poland, Spain and Sweden and examines the ability of national diagnosis-related group (DRG) systems to explain the variation in resource use against a set of patient characteristic and treatment specific variables. In total, 195,810 cases clustered in 712 hospitals were analyzed using OLS fixed effects models for cost data (n=125,698) and negative binominal models for length-of-stay data (n=70,112). The number of DRGs differs widely across the 10 European countries (range: 2-14). Underlying this wide range is a different use of classification variables, especially secondary diagnoses and treatment options are considered to a different extent. In six countries, a standard set of patient characteristics and treatment variables explain the variation in costs or length of stay better than the DRG variables. This raises questions about the adequacy of the countries' DRG system or the lack of specific criteria, which could be used as classification variables. Copyright © 2012 John Wiley & Sons, Ltd.

Experts' perspectives on SwissDRG: Second class care for vulnerable patient groups?

PubMed

Leu, A; Wepf, H; Elger, B; Wangmo, T

2018-03-14

On the 1st of January 2012, Switzerland introduced the diagnosis-related group hospital tariff structure (SwissDRG). It was recognised that healthcare provided to the most vulnerable patient groups would be a challenge for the new SwissDRG. Coincident with the implementation of SwissDRG, we explored hospital experts' perceptions of which patient groups are vulnerable under the SwissDRG system, what has changed for this group, as well as solutions to ensure adequate access to health care for them. We interviewed 43 experts from 40 Swiss hospitals. Participating experts named several vulnerable patient groups who share some common characteristics. These hospital experts were concerned about the patient groups that are not financially profitable and questioned the practicability of the current regulation. At the same time, they highlighted the complexity associated with caring for this group under the new SwissDRG and reported measures at the macro, meso, and micro levels to protect vulnerable patient groups from negative effects. To curb negative outcomes for vulnerable patient groups after the introduction of the SwissDRG, the Swiss legislation has introduced various instruments including the acute and transitional care (ATC) measures. We conclude that ATC measures do not produce the expected effect the legislators had hoped for. More health data is needed to identify situations where vulnerable patient groups are more susceptible to inadequate health care access in Switzerland. Copyright © 2018 Elsevier B.V. All rights reserved.

Physically disconnected non-diffusible cell-to-cell communication between neuroblastoma SH-SY5Y and DRG primary sensory neurons.

PubMed

Chaban, Victor V; Cho, Taehoon; Reid, Christopher B; Norris, Keith C

2013-01-01

Cell-cell communication occurs via a variety of mechanisms, including long distances (hormonal), short distances (paracrine and synaptic) or direct coupling via gap junctions, antigen presentation, or ligand-receptor interactions. We evaluated the possibility of neuro-hormonal independent, non-diffusible, physically disconnected pathways for cell-cell communication using dorsal root ganglion (DRG) neurons. We assessed intracellular calcium ([Ca(2+)]) in primary culture DRG neurons that express ATP-sensitive P2X3, capsaicinsensitive TRPV1 receptors modulated by estradiol. Physically disconnected (dish-in-dish system; inner chamber enclosed) mouse DRG were cultured for 12 hours near: a) media alone (control 1), b) mouse DRG (control 2), c) human neuroblastoma SHSY-5Y cells (cancer intervention), or d) mouse DRG treated with KCl (apoptosis intervention). Chemosensitive receptors [Ca(2+)](i) signaling did not differ between control 1 and 2. ATP (10 μM) and capsaicin (100nM) increased [Ca(2+)](i) transients to 425.86 + 49.5 nM, and 399.21 ± 44.5 nM, respectively. 17β-estradiol (100 nM) exposure reduced ATP (171.17 ± 48.9 nM) and capsaicin (175.01±34.8 nM) [Ca(2+)](i) transients. The presence of cancer cells reduced ATP- and capsaicin-induced [Ca(2+)](i) by >50% (p<0.05) and abolished the 17β-estradiol effect. By contrast, apoptotic DRG cells increased initial ATP-induced [Ca(2+)](i), flux four fold and abolished subsequent [Ca(2+)](i), responses to ATP stimulation (p<0.001). Capsaicin (100nM) induced [Ca(2+)](i) responses were totally abolished. The local presence of apoptotic DRG or human neuroblastoma cells induced differing abnormal ATP and capsaicin-mediated [Ca(2+)](i) fluxes in normal DRG. These findings support physically disconnected, non-diffusible cell-to-cell signaling. Further studies are needed to delineate the mechanism(s) of and model(s) of communication.

[DRG-based cost analysis of inpatient conservative treatment of stage III/IV peripheral arterial occlusive disease].

PubMed

Heidrich, H; Rogatti, W; Altmann, E; Bauersachs, R; Diehm, C; Fahrig, C; Lawall, H; Ranft, J; Schenker, M; Schweizer, H J; Stiegler, H; Wilke, M

2003-11-01

DRG-based cost analysis of inpatient conservative treatment of PAD stage III/IV BACKGROUND: In a prospective study carried out by the German Society of Angiology and the DRG Competence Center, Munich, the question was investigated whether the costs of conservative treatment of patients with PAOD stage III/IV (DRG F65) are adequately represented within the current G-DRG system. METHODS UND PATIENTS: Between September 1 and December 16, 2002, a total of 704 patients with DRG F65 (peripheral vascular diseases) were evaluated at 8 angiologic centers in Germany. Apart from the length of hospital stay, the total costs (cost equivalents) were calculated using a method developed by the DRG Research Group at the University of Münster. Moreover, the study population was compared with a German calculation sample for the DRGs F65A/B, as published by InEK. As it turned out, conservatively treated patients with PAOD stage III or IV (DRGs F65A/B) cause significantly (p < 0.001) higher costs and have significantly (p < 0.001) greater lengths of hospital stay than patients who were also assigned to DRG F65 because of other vascular diseases. At the same time it became clear that angiologic centers treat twice as many patients with critical limb ischemia in comparison with the German average. The reimbursement hitherto estimated by InEK covers not even half the cost actually produced by conservative treatment of PAD stage III/IV. To ensure a performance-related reimbursement, a new basis DRG for patients with PAD stage III/IV has to be created, as has ben proposed by the German Society of Angiology. Otherwise, adequate conservative therapy in accordance with existing guidelines, of patients who cannot be treated surgically or interventionally will not be possible any more in the future.

Development of MY-DRG casemix pharmacy service weights in UKM Medical Centre in Malaysia.

PubMed

Ali Jadoo, Saad Ahmed; Aljunid, Syed Mohamed; Nur, Amrizal Muhammad; Ahmed, Zafar; Van Dort, Dexter

2015-02-10

The service weight is among several issues and challenges in the implementation of case-mix in developing countries, including Malaysia. The aim of this study is to develop the Malaysian Diagnosis Related Group (MY-DRG) case-mix pharmacy service weight in University Kebangsaan Malaysia-Medical Center (UKMMC) by identifying the actual cost of pharmacy services by MY-DRG groups in the hospital. All patients admitted to UKMMC in 2011 were recruited in this study. Combination of Step-down and Bottom-up costing methodology has been used in this study. The drug and supplies cost; the cost of staff; the overhead cost; and the equipment cost make up the four components of pharmacy. Direct costing approach has been employed to calculate Drugs and supplies cost from electronic-prescription system; and the inpatient pharmacy staff cost, while the overhead cost and the pharmacy equipments cost have been calculated indirectly from MY-DRG data base. The total pharmacy cost was obtained by summing the four pharmacy components' cost per each MY-DRG. The Pharmacy service weight of a MY-DRG was estimated by dividing the average pharmacy cost of the investigated MY-DRG on the average of a specified MY-DRG (which usually the average pharmacy cost of all MY-DRGs). Drugs and supplies were the main component (86.0%) of pharmacy cost compared o overhead cost centers (7.3%), staff cost (6.5%) and pharmacy equipments (0.2%) respectively. Out of 789 inpatient MY-DRGs case-mix groups, 450 (57.0%) groups were utilized by the UKMMC. Pharmacy service weight has been calculated for each of these 450 MY-DRGs groups. MY-DRG case-mix group of Lymphoma & Chronic Leukemia group with severity level three (C-4-11-III) has the highest pharmacy service weight of 11.8 equivalents to average pharmacy cost of RM 5383.90. While the MY-DRG case-mix group for Circumcision with severity level one (V-1-15-I) has the lowest pharmacy service weight of 0.04 equivalents to average pharmacy cost of RM 17.83. A mixed approach which is based partly on top-down and partly on bottom up costing methodology has been recruited to develop MY-DRG case-mix pharmacy service weight for 450 groups utilized by the UKMMC in 2011.

Investigation of the effect of phase nonuniformities and the microwave field distribution on the electronic efficiency of a diffraction-radiation generator

NASA Astrophysics Data System (ADS)

Maksimov, P. P.; Tsvyk, A. I.; Shestopalov, V. P.

1985-10-01

The effect of local phase nonuniformities of the diffraction gratings and the field distribution of the open cavity on the electronic efficiency of a diffraction-radiation generator (DRG) is analyzed numerically on the basis of a self-consistent system of nonlinear stationary equations for the DRG. It is shown that the interaction power and efficiency of a DRG can be increased by the use of an open cavity with a nonuniform diffraction grating and a complex form of microwave field distribution over the interaction space.

HSV-1 interaction to 3-O-sulfated heparan sulfate in mouse-derived DRG explant and profiles of inflammatory markers during virus infection.

PubMed

Sharthiya, Harsh; Seng, Chanmoly; Van Kuppevelt, T H; Tiwari, Vaibhav; Fornaro, Michele

2017-06-01

The molecular mechanism of herpes simplex virus (HSV) entry and the associated inflammatory response in the nervous system remain poorly understood. Using mouse-derived ex vivo dorsal root ganglia (DRG) explant model and single cell neurons (SCNs), in this study, we provided a visual evidence for the expression of heparan sulfate (HS) and 3-O-sulfated heparan sulfate (3-OS HS) followed by their interactions with HSV-1 glycoprotein B (gB) and glycoprotein D (gD) during cell entry. Upon heparanase treatment of DRG-derived SCN, a significant inhibition of HSV-1 entry was observed suggesting the involvement of HS role during viral entry. Finally, a cytokine array profile generated during HSV-1 infection in DRG explant indicated an enhanced expression of chemokines (LIX, TIMP-2, and M-CSF)-known regulators of HS. Taken together, these results highlight the significance of HS during HSV-1 entry in DRG explant. Further investigation is needed to understand which isoforms of 3-O-sulfotransferase (3-OST)-generated HS contributed during HSV-1 infection and associated cell damage.

[Representation of cystectomy and urinary diversion in the G-DRG system 2010: an example for the complexity of the reimbursement system].

PubMed

Volkmer, B; Petervari, M; de Geeter, P

2011-01-01

Cystectomy and urinary diversion is an excellent example for the growing complexity of the G-DRG (German diagnosis-related groups) system. Based on different diagnoses (malignant tumor of the urinary tract, benign disease of the urinary tract, malignant tumor of the female genital tract, or malignant tumor of the male genital tract), identical cases may lead to very different codes, resulting in even more differences in reimbursement.

Economic incentives and diagnostic coding in a public health care system.

PubMed

Anthun, Kjartan Sarheim; Bjørngaard, Johan Håkon; Magnussen, Jon

2017-03-01

We analysed the association between economic incentives and diagnostic coding practice in the Norwegian public health care system. Data included 3,180,578 hospital discharges in Norway covering the period 1999-2008. For reimbursement purposes, all discharges are grouped in diagnosis-related groups (DRGs). We examined pairs of DRGs where the addition of one or more specific diagnoses places the patient in a complicated rather than an uncomplicated group, yielding higher reimbursement. The economic incentive was measured as the potential gain in income by coding a patient as complicated, and we analysed the association between this gain and the share of complicated discharges within the DRG pairs. Using multilevel linear regression modelling, we estimated both differences between hospitals for each DRG pair and changes within hospitals for each DRG pair over time. Over the whole period, a one-DRG-point difference in price was associated with an increased share of complicated discharges of 14.2 (95 % confidence interval [CI] 11.2-17.2) percentage points. However, a one-DRG-point change in prices between years was only associated with a 0.4 (95 % CI [Formula: see text] to 1.8) percentage point change of discharges into the most complicated diagnostic category. Although there was a strong increase in complicated discharges over time, this was not as closely related to price changes as expected.

Developmentally regulated GTP-binding protein 2 depletion leads to mitochondrial dysfunction through downregulation of dynamin-related protein 1

DOE Office of Scientific and Technical Information (OSTI.GOV)

Vo, Mai-Tram; Ko, Myoung Seok; Lee, Unn Hwa

Mitochondrial dynamics, including constant fusion and fission, play critical roles in maintaining mitochondrial morphology and function. Here, we report that developmentally regulated GTP-binding protein 2 (DRG2) regulates mitochondrial morphology by modulating the expression of the mitochondrial fission gene dynamin-related protein 1 (Drp1). shRNA-mediated silencing of DRG2 induced mitochondrial swelling, whereas expression of an shRNA-resistant version of DRG2 decreased mitochondrial swelling in DRG2-depleted cells. Analysis of the expression levels of genes involved in mitochondrial fusion and fission revealed that DRG2 depletion significantly decreased the level of Drp1. Overexpression of Drp1 rescued the defect in mitochondrial morphology induced by DRG2 depletion. DRG2more » depletion reduced the mitochondrial membrane potential, oxygen consumption rate (OCR), and amount of mitochondrial DNA (mtDNA), whereas it increased reactive oxygen species (ROS) production and apoptosis. Taken together, our data demonstrate that DRG2 acts as a regulator of mitochondrial fission by controlling the expression of Drp1. - Highlights: • DRG2 depletion increased mitochondrial swelling. • DRG2 depletion inhibited the expression of Drp1. • Overexpression of DRG2 or Drp1 rescued mitochondrial shape in DRG2 depleted cells. • DRG2 depletion induced mitochondrial dysfunction.« less

Bidirectional communication between sensory neurons and osteoblasts in an in vitro coculture system.

PubMed

Kodama, Daisuke; Hirai, Takao; Kondo, Hisataka; Hamamura, Kazunori; Togari, Akifumi

2017-02-01

Recent studies have revealed that the sensory nervous system is involved in bone metabolism. However, the mechanism of communication between neurons and osteoblasts is yet to be elucidated. In this study, we investigated the signaling pathways between sensory neurons of the dorsal root ganglion (DRG) and the osteoblast-like MC3T3-E1 cells using an in vitro coculture system. Our findings indicate that signal transduction from DRG-derived neurons to MC3T3-E1 cells is suppressed by antagonists of the AMPA receptor and the NK 1 receptor. Conversely, signal transduction from MC3T3-E1 cells to DRG-derived neurons is suppressed by a P2X 7 receptor antagonist. Our results suggest that these cells communicate with each other by exocytosis of glutamate, substance P in the efferent signal, and ATP in the afferent signal. © 2017 Federation of European Biochemical Societies.

Viral vector mediated continuous expression of interleukin-10 in DRG alleviates pain in type 1 diabetic animals.

PubMed

Thakur, Vikram; Gonzalez, Mayra; Pennington, Kristen; Chattopadhyay, Munmun

2016-04-01

Painful diabetic neuropathy is a common and difficult to treat complication of diabetes. A growing body of evidence implicates the role of inflammatory mediators in the damage to the peripheral axons and in the pathogenesis of neuropathic pain. Increased expression of pro-inflammatory cytokines such as interleukin (IL)-1β and tumor necrosis factor (TNF)-α in the peripheral nervous system suggests the possibility of change in pain perception in diabetes. In this study we investigated that continuous delivery of IL10 in the nerve fibers achieved by HSV vector mediated transduction of dorsal root ganglion (DRG) in animals with Type 1 diabetes, blocks the nociceptive and stress responses in the DRG neurons by reducing IL1β expression along with inhibition of phosphorylation of p38 MAPK (mitogen-activated protein kinase) and protein kinase C (PKC). The continuous expression of IL10 also alters Toll like receptor (TLR)-4 expression in the DRG with increased expression of heat shock protein (HSP)-70 in conjunction with the reduction of pain. Taken together, this study suggests that macrophage activation in the peripheral nervous system may be involved in the pathogenesis of pain in Type 1 diabetes and therapeutic benefits of HSV mediated local expression of IL10 in the DRG with the reduction of a number of proinflammatory cytokines, subsequently inhibits the development of painful neuropathy along with a decrease in stress associated markers in the DRG. This basic and preclinical study provides an important evidence for a novel treatment strategy that could lead to a clinical trial for what is currently a treatment resistant complication of diabetes. Copyright © 2016 Elsevier Inc. All rights reserved.

Stress activates pronociceptive endogenous opioid signalling in DRG neurons during chronic colitis.

PubMed

Guerrero-Alba, Raquel; Valdez-Morales, Eduardo E; Jimenez-Vargas, Nestor N; Lopez-Lopez, Cintya; Jaramillo-Polanco, Josue; Okamoto, Takanobu; Nasser, Yasmin; Bunnett, Nigel W; Lomax, Alan E; Vanner, Stephen J

2017-12-01

Psychological stress accompanies chronic inflammatory diseases such as IBD, and stress hormones can exacerbate pain signalling. In contrast, the endogenous opioid system has an important analgesic action during chronic inflammation. This study examined the interaction of these pathways. Mouse nociceptive dorsal root ganglia (DRG) neurons were incubated with supernatants from segments of inflamed colon collected from patients with chronic UC and mice with dextran sodium sulfate (cDSS)-induced chronic colitis. Stress effects were studied by adding stress hormones (epinephrine and corticosterone) to dissociated neurons or by exposing cDSS mice to water avoidance stress. Changes in excitability of colonic DRG nociceptors were measured using patch clamp and Ca 2+ imaging techniques. Supernatants from patients with chronic UC and from colons of mice with chronic colitis caused a naloxone-sensitive inhibition of neuronal excitability and capsaicin-evoked Ca 2+ responses. Stress hormones decreased signalling induced by human and mouse supernatants. This effect resulted from stress hormones signalling directly to DRG neurons and indirectly through signalling to the immune system, leading to decreased opioid levels and increased acute inflammation. The net effect of stress was a change endogenous opioid signalling in DRG neurons from an inhibitory to an excitatory effect. This switch was associated with a change in G protein-coupled receptor excitatory signalling to a pathway sensitive to inhibitors of protein kinase A-protein, phospholipase C-protein and G protein βϒ subunits. Stress hormones block the inhibitory actions of endogenous opioids and can change the effect of opioid signalling in DRG neurons to excitation. Targeting these pathways may prevent heavy opioid use in IBD. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Geographic variations in orthopedic trauma billing and reimbursements for hip and pelvis fractures in the Medicare population.

PubMed

Dodd, Ashley C; Lakomkin, Nikita; Bulka, Catherine; Thakore, Rachel; Collinge, Cory A; Sethi, Manish K

2016-12-01

We investigated geographic variations in Medicare spending for DRG 536 (hip and pelvis fracture). We identified 22,728 patients. The median number of charges, discharges, and payments were recorded. Hospitals were aggregated into core based statistical (CBS) areas and the coefficient of variation (CV) was calculated for each area. On average, hospitals charged 3.75 times more than they were reimbursed. Medicare charges and reimbursements demonstrated variability within each area. Geographic variation in Medicare spending for hip fractures is currently unexplained. It is imperative for orthopedists to understand drivers behind such high variability in hospital charges for management of hip and pelvis fractures.

Impact of the DRG System in Arizona. Hearing before the Subcommittee on Health and Long-Term Care of the Select Committee on Aging. House of Representatives, Ninety-Ninth Congress, First Session (September 14, 1985, Tucson, AZ).

ERIC Educational Resources Information Center

Congress of the U.S., Washington, DC. House Select Committee on Aging.

Text of a Congressional hearing held in Tucson, Arizona, to examine health care and the diagnostic related group (DRG) system is presented in this document. Opening statements are delivered by Representatives Kolbe and McCain. Witnesses testifying include: (1) two older Arizona residents who had experienced problems related to diagnostic related…

Price Changes in Regulated Healthcare Markets: Do Public Hospitals Respond and How?

PubMed

Verzulli, Rossella; Fiorentini, Gianluca; Lippi Bruni, Matteo; Ugolini, Cristina

2017-11-01

This paper examines the behaviour of public hospitals in response to the average payment incentives created by price changes for patients classified in different diagnosis-related groups (DRGs). Using panel data on public hospitals located within the Italian region of Emilia-Romagna, we test whether a 1-year increase in DRG prices induced public hospitals to increase their volume of activity and whether a potential response is associated with changes in waiting times and/or length of stay. We find that public hospitals reacted to the policy change by increasing the number of patients with surgical treatments. This effect was smaller in the 2 years after the policy change than in later years, and for providers with a lower excess capacity in the pre-policy period, whereas it did not vary significantly across hospitals according to their degree of financial and administrative autonomy. For patients with medical DRGs, instead, there appeared to be no effect on inpatient volumes. Our estimates also suggest that an increase in DRG prices had no impact on the proportion of patients waiting more than 6 months. Finally, we find no evidence of a significant effect on patients' average length of stay. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Isl-1 down-regulates DRG cell proliferation during chicken embryo development.

PubMed

Chen, Dawei; Wang, Guoxin; Luo, Haoshu; Liu, Jiali; Cui, Sheng

2010-01-01

Protein Isl-1 RNA interference and over expression in early chicken embryo dorsal root ganglia (DRG) were used to investigate the function of Isl-1 in DRG cell proliferation. Isl-1 targeted shRNA expression vector and Isl-1 over-expression vector were transfected into chicken embryo DRG by in ovo electroporation. Then, the DRG proliferation rate was detected by BrdU immunohistochemistry. The rate of DRG cell proliferation increased after Isl-1 knock-down and decreased after Isl-1 over-expression. In this study, we found that Isl-1 negatively modulates DRG cell proliferation.

AAV-Mediated Gene Transfer to Dorsal Root Ganglion.

PubMed

Yu, Hongwei; Fischer, Gregory; Hogan, Quinn H

2016-01-01

Transferring genetic molecules into the peripheral sensory nervous system to manipulate nociceptive pathophysiology is a powerful approach for experimental modulation of sensory signaling and potentially for translation into therapy for chronic pain. This can be efficiently achieved by the use of recombinant adeno-associated virus (rAAV) in conjunction with nociceptor-specific regulatory transgene cassettes. Among different routes of delivery, direct injection into the dorsal root ganglia (DRGs) offers the most efficient AAV-mediated gene transfer selectively into the peripheral sensory nervous system. Here, we briefly discuss the advantages and applications of intraganglionic microinjection, and then provide a detailed approach for DRG injection, including a list of the necessary materials and description of a method for performing DRG microinjection experiments. We also discuss our experience with several adeno-associated virus (AAV) options for in vivo transgene expression in DRG neurons.

[Inpatient therapy of urinary stones in Germany: development of the G-DRG system].

PubMed

Bauer, J; Kahlmeyer, A; Stredele, R; Volkmer, B G

2014-12-01

The therapy of urinary stones in Germany is mostly a domain of hospitals even now. With the introduction of the German diagnosis-related groups (G-DRG) system in the years 2003/2004 an attempt was made to realize an ever-increasing fair representation and remuneration of treatment costs. Simultaneously, a declared target was to transfer all forms of treatment which did not necessitate hospital admission to the outpatient department. Analysis of the D-DRG data on running invoicing from all German hospitals from 2004/2005 to 2012/2013 showed an increase in case numbers of around 12% with a parallel increase in the volume of revenues of around 37%. A special feature was a reduction in the proportion of extracorporeal shockwave therapy (ESWL) as inpatient treatment with a parallel increase in the proportion of ureteroscopic and percutaneous interventions.

Distinct degree of radiculopathy at different levels of peripheral nerve injury

PubMed Central

2012-01-01

Background Lumbar radiculopathy is a common clinical problem, characterized by dorsal root ganglion (DRG) injury and neural hyperactivity causing intense pain. However, the mechanisms involved in DRG injury have not been fully elucidated. Furthermore, little is known about the degree of radiculopathy at the various levels of nerve injury. The purpose of this study is to compare the degree of radiculopathy injury at the DRG and radiculopathy injury proximal or distal to the DRG. Results The lumbar radiculopathy rat model was created by ligating the L5 nerve root 2 mm proximal to the DRG or 2 mm distal to the DRG with 6.0 silk. We examined the degree of the radiculopathy using different points of mechanical sensitivity, immunohistochemistry and in vivo patch-clamp recordings, 7 days after surgery. The rats injured distal to the DRG were more sensitive than those rats injured proximal to the DRG in the behavioral study. The number of activated microglia in laminas I–II of the L5 segmental level was significantly increased in rats injured distal to the DRG when compared with rats injured proximal to the DRG. The amplitudes and frequencies of EPSC in the rats injured distal to the DRG were higher than those injured proximal to the DRG. The results indicated that there is a different degree of radiculopathy at the distal level of nerve injury. Conclusions Our study examined the degree of radiculopathy at different levels of nerve injury. Severe radiculopathy occurred in rats injured distal to the DRG when compared with rats injured proximal to the DRG. This finding helps to correctly diagnose a radiculopathy. PMID:22537715

Casemix funding for acute hospital inpatient services in Australia.

PubMed

Duckett, S J

1998-10-19

Casemix funding was introduced first in Victoria in 1993-94, and since then most States have moved towards either casemix funding or using casemix to inform the budget setting process. The five States implementing casemix have adopted some common funding elements: all use AN-DRG-3; all have introduced capping, msot commonly at the hospital level; and all ensure accuracy of diagnosis and procedure coding through coding audits. Two funding models have been developed. The fixed and variable model involves a fixed grant for hospital overhead costs and a payment for each patient treated, covering only variable costs. The integrated model provides an integrated payment to hospitals for each patient treated, covering both the fixed and variable costs. There are different weight setting processes and base prices between the States, which result in marked differences in the price paid for the same type of case treated in similar hospitals. Learning across State boundaries should be encouraged, with knowledge of what is effective and what is ineffective in casemix funding arrangements being used to develop Australian best practice in this area.

[Development of DRG-reimbursement in hand surgery].

PubMed

Lotter, O; Stahl, S; Nyszkiewicz, R; Schaller, H-E

2011-02-01

Since the introduction of Diagnosis Related Groups (DRGs) in 2004 in Germany the variables of remuneration changed continuously. Subjectively, reimbursement of DRG in hand surgery has a negative connotation among colleagues. We analyzed the development of reimbursement as well as the length of stay of inpatients over time in Hand Surgery considering various parameters concentrating on trends and correlation with macroeconomic parameters. The Top 10 diagnoses and therapies between 2004 and 2010 in our clinic were grouped and resulting DRGs with further linked data could be obtained. In addition to the Base Rate the Pay Base Rate (the effective Base Rate in a certain hospital considering compensatory payment) and the Z-Bax (the value that was reimbursed by the national health insurance per Base Rate) were used to calculate reimbursement. These were multiplied with the number of cases treated in 2009 obtaining the different total annual remuneration. The lower threshold of length of stay was constant over time, the middle length of stay became shorter in most of the Top 10 diagnoses whereas the upper threshold of length of stay was reduced to half of the time. The Base Rate and the Pay Base Rate increased by the end of the period but were outmatched by the Z-Bax as an indicator for the general level of reimbursement in Germany. Total remuneration between 2004 and 2009 was compared applying the Z-Bax and the Base Rate as well as the Pay Base Rate, respectively. For the latter, a surplus of 244 000 Euros and 311 000 Euros were calculated, respectively. No correlation with the Gross National Product or the Rate of Inflation could be found. The Pay Base Rate as the rate of effective payment in our clinic declined by 7% whereas the consumer price index gained 8,6% resulting in a loss of purchasing power of almost 16% in a 6-year period. © Georg Thieme Verlag KG Stuttgart · New York.

Realization of intermode oscillations in open resonator of diffraction radiation generator

NASA Astrophysics Data System (ADS)

Kurin, V. G.; Skrynnik, V. G.; Shestopalov, V. P.

1993-11-01

The results of an experimental study of oscillation interaction in the open resonator of a diffraction radiation generator (DRG) are presented. Interaction is obtained in the region of oscillation splitting in the electrodynamic system of the DRG in the diffraction-radiation mode. The possibility of improving the generator's frequency stability in the vicinities of Morse critical points is shown.

FPGA platform for MEMS Disc Resonance Gyroscope (DRG) control

NASA Astrophysics Data System (ADS)

Keymeulen, Didier; Peay, Chris; Foor, David; Trung, Tran; Bakhshi, Alireza; Withington, Phil; Yee, Karl; Terrile, Rich

2008-04-01

Inertial navigation systems based upon optical gyroscopes tend to be expensive, large, power consumptive, and are not long lived. Micro-Electromechanical Systems (MEMS) based gyros do not have these shortcomings; however, until recently, the performance of MEMS based gyros had been below navigation grade. Boeing and JPL have been cooperating since 1997 to develop high performance MEMS gyroscopes for miniature, low power space Inertial Reference Unit applications. The efforts resulted in demonstration of a Post Resonator Gyroscope (PRG). This experience led to the more compact Disc Resonator Gyroscope (DRG) for further reduced size and power with potentially increased performance. Currently, the mass, volume and power of the DRG are dominated by the size of the electronics. This paper will detail the FPGA based digital electronics architecture and its implementation for the DRG which will allow reduction of size and power and will increase performance through a reduction in electronics noise. Using the digital control based on FPGA, we can program and modify in real-time the control loop to adapt to the specificity of each particular gyro and the change of the mechanical characteristic of the gyro during its life time.

Financial impact of introducing the Swiss-DRG reimbursement system on potentially avoidable readmissions at a university hospital.

PubMed

Wasserfallen, Jean-Blaise; Zufferey, Jade

2015-01-01

Thirty-day readmissions can be classified as potentially avoidable (PARs) or not avoidable (NARs) by following a specific algorithm (SQLape®). We wanted to assess the financial impact of the Swiss-DRG system, which regroups some readmissions occurring within 18 days after discharge within the initial hospital stay, on PARs at our hospital. First, PARs were identified from all hospitalisations recorded in 2011 at our university hospital. Second, 2012 Swiss-DRG readmission rules were applied, regrouped readmissions (RR) were identified, and their financial impact computed. Third, RRs were classified as potentially avoidable (PARRs), not avoidable (NARRs), and others causes (OCRRs). Characteristics of PARR patients and stays were retrieved, and the financial impact of PARRS was computed. A total of 36,777 hospitalisations were recorded in 2011, of which 3,140 were considered as readmissions (8.5%): 1,470 PARs (46.8%) and 1,733 NARs (53.2%). The 2012 Swiss-DRG rules would have resulted in 910 RRs (2.5% of hospitalisations, 29% of readmissions): 395 PARRs (43% of RR), 181 NARRs (20%), and 334 OCRRs (37%). Loss in reimbursement would have amounted to CHF 3.157 million (0.6% of total reimbursement). As many as 95% of the 395 PARR patients lived at home. In total, 28% of PARRs occurred within 3 days after discharge, and 58% lasted less than 5 days; 79% of the patients were discharged home again. Loss in reimbursement would amount to CHF 1.771 million. PARs represent a sizeable number of 30-day readmissions, as do PARRs of 18-day RRs in the 2012 Swiss DRG system. They should be the focus of attention, as the PARRs represent an avoidable loss in reimbursement.

Augmentation of glycolytic metabolism by meclizine is indispensable for protection of dorsal root ganglion neurons from hypoxia-induced mitochondrial compromise.

PubMed

Zhuo, Ming; Gorgun, Murat F; Englander, Ella W

2016-10-01

To meet energy demands, dorsal root ganglion (DRG) neurons harbor high mitochondrial content, which renders them acutely vulnerable to disruptions of energy homeostasis. While neurons typically rely on mitochondrial energy production and have not been associated with metabolic plasticity, new studies reveal that meclizine, a drug, recently linked to modulations of energy metabolism, protects neurons from insults that disrupt energy homeostasis. We show that meclizine rapidly enhances glycolysis in DRG neurons and that glycolytic metabolism is indispensable for meclizine-exerted protection of DRG neurons from hypoxic stress. We report that supplementation of meclizine during hypoxic exposure prevents ATP depletion, preserves NADPH and glutathione stores, curbs reactive oxygen species (ROS) and attenuates mitochondrial clustering in DRG neurites. Using extracellular flux analyzer, we show that in cultured DRG neurons meclizine mitigates hypoxia-induced loss of mitochondrial respiratory capacity. Respiratory capacity is a measure of mitochondrial fitness and cell ability to meet fluctuating energy demands and therefore, a key determinant of cellular fate. While meclizine is an 'old' drug with long record of clinical use, its ability to modulate energy metabolism has been uncovered only recently. Our findings documenting neuroprotection by meclizine in a setting of hypoxic stress reveal previously unappreciated metabolic plasticity of DRG neurons as well as potential for pharmacological harnessing of the newly discovered metabolic plasticity for protection of peripheral nervous system under mitochondria compromising conditions. Copyright © 2016 Elsevier Inc. All rights reserved.

Wnt3 and Gata4 regulate axon regeneration in adult mouse DRG neurons.

PubMed

Duan, Run-Shan; Liu, Pei-Pei; Xi, Feng; Wang, Wei-Hua; Tang, Gang-Bin; Wang, Rui-Ying; Saijilafu; Liu, Chang-Mei

2018-05-05

Neurons in the adult central nervous system (CNS) have a poor intrinsic axon growth potential after injury, but the underlying mechanisms are largely unknown. Wingless-related mouse mammary tumor virus integration site (WNT) family members regulate neural stem cell proliferation, axon tract and forebrain development in the nervous system. Here we report that Wnt3 is an important modulator of axon regeneration. Downregulation or overexpression of Wnt3 in adult dorsal root ganglion (DRG) neurons enhances or inhibits their axon regeneration ability respectively in vitro and in vivo. Especially, we show that Wnt3 modulates axon regeneration by repressing mRNA translation of the important transcription factor Gata4 via binding to the three prime untranslated region (3'UTR). Downregulation of Gata4 could restore the phenotype exhibited by Wnt3 downregulation in DRG neurons. Taken together, these data indicate that Wnt3 is a key intrinsic regulator of axon growth ability of the nervous system. Copyright © 2018 Elsevier Inc. All rights reserved.

Reimbursement of burns by DRG in four European countries: an analysis.

PubMed

Lotter, O; Jaminet, P; Amr, A; Chiarello, P; Schaller, H E; Rahmanian-Schwarz, A

2011-11-01

To analyze the German, Austrian, Italian and Spanish Diagnosis-Related Group (DRG)-systems regarding burns. We analyzed 78 cases of inpatients with burns which were processed by national DRG-groupers. DRGs were linked to thresholds concerning length of stay as well as reimbursement tables of the respective countries. Fifty-one % of cases showed higher reimbursement in Germany compared to Austria, 55% compared to Italy and 67% as against Spain. Total proceeds are highest in Austria with 1,577,000 €, followed by Italy with 1,569,000 €, Germany with 1,502,000 € and Spain with 902,596 €. No correlation was found between macroeconomic key figures and our data. International comparison of reimbursement of burns by DRG could be a useful instrument for benchmarking while not depending solely on political decisions or country-specific cost data. For better comparability, hospital indices based on healthcare baskets should be discussed. Copyright © 2011 Elsevier Ltd and ISBI. All rights reserved.

Australian diagnosis related groups: Drivers of complexity adjustment.

PubMed

Jackson, Terri; Dimitropoulos, Vera; Madden, Richard; Gillett, Steve

2015-11-01

In undertaking a major revision to the Australian Refined Diagnosis Related Group (ARDRG) classification, we set out to contrast Australia's approach to using data on additional (not principal) diagnoses with major international approaches in splitting base or Adjacent Diagnosis Related Groups (ADRGs). Comparative policy analysis/narrative review of peer-reviewed and grey literature on international approaches to use of additional (secondary) diagnoses in the development of Australian and international DRG systems. European and US approaches to characterise complexity of inpatient care are well-documented, providing useful points of comparison with Australia's. Australia, with good data sources, has continued to refine its national DRG classification using increasingly sophisticated approaches. Hospital funders in Australia and in other systems are often under pressure from provider groups to expand classifications to reflect clinical complexity. DRG development in most healthcare systems reviewed here reflects four critical factors: these socio-political factors, the quality and depth of the coded data available to characterise the mix of cases in a healthcare system, the size of the underlying population, and the intended scope and use of the classification. Australia's relatively small national population has constrained the size of its DRG classifications, and development has been concentrated on inpatient care in public hospitals. Development of casemix classifications in health care is driven by both technical and socio-political factors. Use of additional diagnoses to adjust for patient complexity and cost needs to respond to these in each casemix application. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Peptidomics and Secretomics of the Mammalian Peripheral Sensory-Motor System

NASA Astrophysics Data System (ADS)

Tillmaand, Emily G.; Yang, Ning; Kindt, Callie A. C.; Romanova, Elena V.; Rubakhin, Stanislav S.; Sweedler, Jonathan V.

2015-12-01

The dorsal root ganglion (DRG) and its anatomically and functionally associated spinal nerve and ventral and dorsal roots are important components of the peripheral sensory-motor system in mammals. The cells within these structures use a number of peptides as intercellular signaling molecules. We performed a variety of mass spectrometry (MS)-based characterizations of peptides contained within and secreted from these structures, and from isolated and cultured DRG cells. Liquid chromatography-Fourier transform MS was utilized in DRG and nerve peptidome analysis. In total, 2724 peptides from 296 proteins were identified in tissue extracts. Neuropeptides are among those detected, including calcitonin gene-related peptide I, little SAAS, and known hemoglobin-derived peptides. Solid phase extraction combined with direct matrix-assisted laser desorption/ionization time-of-flight MS was employed to investigate the secretome of these structures. A number of peptides were detected in the releasate from semi-intact preparations of DRGs and associated nerves, including neurofilament- and myelin basic protein-related peptides. A smaller set of analytes was observed in releasates from cultured DRG neurons. The peptide signals observed in the releasates have been mass-matched to those characterized and identified in homogenates of entire DRGs and associated nerves. This data aids our understanding of the chemical composition of the mammalian peripheral sensory-motor system, which is involved in key physiological functions such as nociception, thermoreception, itch sensation, and proprioception.

Peptidomics and Secretomics of the Mammalian Peripheral Sensory-Motor System.

PubMed

Tillmaand, Emily G; Yang, Ning; Kindt, Callie A C; Romanova, Elena V; Rubakhin, Stanislav S; Sweedler, Jonathan V

2015-12-01

The dorsal root ganglion (DRG) and its anatomically and functionally associated spinal nerve and ventral and dorsal roots are important components of the peripheral sensory-motor system in mammals. The cells within these structures use a number of peptides as intercellular signaling molecules. We performed a variety of mass spectrometry (MS)-based characterizations of peptides contained within and secreted from these structures, and from isolated and cultured DRG cells. Liquid chromatography-Fourier transform MS was utilized in DRG and nerve peptidome analysis. In total, 2724 peptides from 296 proteins were identified in tissue extracts. Neuropeptides are among those detected, including calcitonin gene-related peptide I, little SAAS, and known hemoglobin-derived peptides. Solid phase extraction combined with direct matrix-assisted laser desorption/ionization time-of-flight MS was employed to investigate the secretome of these structures. A number of peptides were detected in the releasate from semi-intact preparations of DRGs and associated nerves, including neurofilament- and myelin basic protein-related peptides. A smaller set of analytes was observed in releasates from cultured DRG neurons. The peptide signals observed in the releasates have been mass-matched to those characterized and identified in homogenates of entire DRGs and associated nerves. This data aids our understanding of the chemical composition of the mammalian peripheral sensory-motor system, which is involved in key physiological functions such as nociception, thermoreception, itch sensation, and proprioception.

Biological constraints limit the use of rapamycin-inducible FKBP12-Inp54p for depleting PIP2 in dorsal root ganglia neurons.

PubMed

Coutinho-Budd, Jaeda C; Snider, Samuel B; Fitzpatrick, Brendan J; Rittiner, Joseph E; Zylka, Mark J

2013-09-08

Rapamycin-induced translocation systems can be used to manipulate biological processes with precise temporal control. These systems are based on rapamycin-induced dimerization of FK506 Binding Protein 12 (FKBP12) with the FKBP Rapamycin Binding (FRB) domain of mammalian target of rapamycin (mTOR). Here, we sought to adapt a rapamycin-inducible phosphatidylinositol 4,5-bisphosphate (PIP2)-specific phosphatase (Inp54p) system to deplete PIP2 in nociceptive dorsal root ganglia (DRG) neurons. We genetically targeted membrane-tethered CFP-FRBPLF (a destabilized FRB mutant) to the ubiquitously expressed Rosa26 locus, generating a Rosa26-FRBPLF knockin mouse. In a second knockin mouse line, we targeted Venus-FKBP12-Inp54p to the Calcitonin gene-related peptide-alpha (CGRPα) locus. We hypothesized that after intercrossing these mice, rapamycin treatment would induce translocation of Venus-FKBP12-Inp54p to the plasma membrane in CGRP+ DRG neurons. In control experiments with cell lines, rapamycin induced translocation of Venus-FKBP12-Inp54p to the plasma membrane, and subsequent depletion of PIP2, as measured with a PIP2 biosensor. However, rapamycin did not induce translocation of Venus-FKBP12-Inp54p to the plasma membrane in FRBPLF-expressing DRG neurons (in vitro or in vivo). Moreover, rapamycin treatment did not alter PIP2-dependent thermosensation in vivo. Instead, rapamycin treatment stabilized FRBPLF in cultured DRG neurons, suggesting that rapamycin promoted dimerization of FRBPLF with endogenous FKBP12. Taken together, our data indicate that these knockin mice cannot be used to inducibly deplete PIP2 in DRG neurons. Moreover, our data suggest that high levels of endogenous FKBP12 could compete for binding to FRBPLF, hence limiting the use of rapamycin-inducible systems to cells with low levels of endogenous FKBP12.

The risk of upcoding in casemix systems: a comparative study.

PubMed

Steinbusch, Paul J M; Oostenbrink, Jan B; Zuurbier, Joost J; Schaepkens, Frans J M

2007-05-01

With the introduction of a diagnosis related group (DRG) classification system in the Netherlands in 2005 it has become relevant to investigate the risk of upcoding. The problem of upcoding in the US casemix system is substantial. In 2004, the US Centres for Medicare and Medicaid estimated that the total number of improper Medicare payments for the Prospective Payment system for acute inpatient care (both short term and long term) amounted to US$ 4.8 billion (5.2%). By comparing the casemix systems in the US, Australian and Dutch healthcare systems, this article illustrates why certain casemix systems are more open to the risk of upcoding than other systems. This study identifies various market, control and casemix characteristics determining the weaknesses of a casemix reimbursement system to upcoding. It can be concluded that fewer opportunities for upcoding occur in casemix systems that do not allow for-profit ownership and in which the coder's salary does not depend on the outcome of the classification process. In addition, casemix systems in which the first point in time of registration is at the beginning of the care process and in which there are a limited number of occasions to alter the registration are less vulnerable to the risk of upcoding. Finally, the risk of upcoding is smaller in casemix systems that use classification criteria that are medically meaningful and aligned with clinical practice. Comparing the US, Australian and Dutch systems the following conclusions can be drawn. Given the combined occurrences of for-profit hospitals and the use of the secondary diagnosis criterion to classify DRGs, the US casemix system tends to be more open to upcoding than the Australian system. The strength of the Dutch system is related to the detailed classification scheme, using medically meaningful classification criteria. Nevertheless, the detailed classification scheme also causes a weakness, because of its increased complexity compared with the US and Australian system. It is recommended that researchers and policy makers carefully consider all relevant market, control and casemix characteristics when developing and restructuring casemix reimbursement systems.

PubMed Central

Formago, Margaret; Schrauder, Michael G.; Rauh, Claudia; Hack, Carolin C.; Jud, Sebastian M.; Hildebrandt, Thomas; Schulz-Wendtland, Rüdiger; Frentz, S.; Graubert, S.; Beckmann, Matthias W.; Lux, Michael P.

2017-01-01

Introduction The care of patients with breast cancer is extremely complex and requires interdisciplinary care in certified facilities. These specialized facilities provide numerous services without being correspondingly remunerated. The question whether breast cancer surgery should be performed in an outpatient setting to reduce costs is increasingly being debated. This study compares inpatient surgical treatment with a model of the same surgery performed on an outpatient basis to examine the potential financial impact. Material and Methods A theoretical model was developed and the DRG fees for surgical interventions to treat primary breast cancer were calculated. A theoretical 1-day DRG was then calculated to permit comparisons with outpatient procedures. The costs of outpatient surgery were calculated based on the remuneration rates of the AOP (Outpatient Surgery) Contract and the EBM (Uniform Assessment Scale) and compared to the costs of the 1-day DRG. Results The DRG fee for both breast-conserving surgery and mastectomy is higher than the fee paid in the context of the EBM system, although the same procedures were carried out in both systems. If a hospital were to carry out breast-conserving surgery as an outpatient procedure, the fee would be € 1313.81; depending on the type of surgery, the hospital would therefore only receive between 39.20% and 52.82% of the DRG fee. This was the case even for a 1-day treatment. Compared to the real DRG fees the difference would be even more striking. Conclusion Carrying out breast cancer surgery as an outpatient procedure would result in a significant shortfall of revenues. Additional services from certified centers, such as the interdisciplinary planning of treatment, psycho-oncological and social-medical care with the involvement of relatives, detailed documentation, etc., which are currently provided without surcharge or adequate remuneration, could no longer be maintained. The quality of processes and excellent results which have been achieved and ultimately the care given by certified facilities would be significantly at risk. PMID:28845052

Should Breast Cancer Surgery Be Done in an Outpatient Setting?: Health Economics From the Perspective of Service Providers.

PubMed

Formago, Margaret; Schrauder, Michael G; Rauh, Claudia; Hack, Carolin C; Jud, Sebastian M; Hildebrandt, Thomas; Schulz-Wendtland, Rüdiger; Frentz, S; Graubert, S; Beckmann, Matthias W; Lux, Michael P

2017-08-01

The care of patients with breast cancer is extremely complex and requires interdisciplinary care in certified facilities. These specialized facilities provide numerous services without being correspondingly remunerated. The question whether breast cancer surgery should be performed in an outpatient setting to reduce costs is increasingly being debated. This study compares inpatient surgical treatment with a model of the same surgery performed on an outpatient basis to examine the potential financial impact. A theoretical model was developed and the DRG fees for surgical interventions to treat primary breast cancer were calculated. A theoretical 1-day DRG was then calculated to permit comparisons with outpatient procedures. The costs of outpatient surgery were calculated based on the remuneration rates of the AOP (Outpatient Surgery) Contract and the EBM (Uniform Assessment Scale) and compared to the costs of the 1-day DRG. The DRG fee for both breast-conserving surgery and mastectomy is higher than the fee paid in the context of the EBM system, although the same procedures were carried out in both systems. If a hospital were to carry out breast-conserving surgery as an outpatient procedure, the fee would be € 1313.81; depending on the type of surgery, the hospital would therefore only receive between 39.20% and 52.82% of the DRG fee. This was the case even for a 1-day treatment. Compared to the real DRG fees the difference would be even more striking. Carrying out breast cancer surgery as an outpatient procedure would result in a significant shortfall of revenues. Additional services from certified centers, such as the interdisciplinary planning of treatment, psycho-oncological and social-medical care with the involvement of relatives, detailed documentation, etc., which are currently provided without surcharge or adequate remuneration, could no longer be maintained. The quality of processes and excellent results which have been achieved and ultimately the care given by certified facilities would be significantly at risk.

[The neurotrophic effect of endogenous NT-3 from adult cat spared dorsal root ganglion on ganglionic neurons].

PubMed

Zhang, Wei; Zhou, Xue; Wang, Ting-hua; Wang, Te-wei; Liu, Su; Chen, Si-xiu; Ou, Ke-qun

2004-01-01

To investigate the neurotrophic effect of endogenous NT-3 from adult cat dorsal root ganglion (DRG) on ganglionic neurons. Rhizotomy of bilateral L1, L3, L5 and L7 dorsal roots of cats was performed, leaving L2, L4 and L6 DRG as spared DRGs. The separate neurons of normal (control) DRG, spared DRG and anti-NT-3 antibody blocking DRG were cultured in vitro respectively. The number of survival neurons and the length of neurites were measured and used for comparison in the control, spared DRG, and block groups. There were survival neurons and cell clusters in every group. The number of survival neurons and cell clusters of spared DRG group were much larger than those of the control and block groups. The neurite length of neurons, the neurite number and the length of cell clusters of spared DRG group were much greater than those of control and block groups. Endogenous NT-3 from spared DRG may act on ganglionic neurons to maintain survival of neuron and stimulate growth of neurite.

Standardized Profiling of The Membrane-Enriched Proteome of Mouse Dorsal Root Ganglia (DRG) Provides Novel Insights Into Chronic Pain.

PubMed

Rouwette, Tom; Sondermann, Julia; Avenali, Luca; Gomez-Varela, David; Schmidt, Manuela

2016-06-01

Chronic pain is a complex disease with limited treatment options. Several profiling efforts have been employed with the aim to dissect its molecular underpinnings. However, generated results are often inconsistent and nonoverlapping, which is largely because of inherent technical constraints. Emerging data-independent acquisition (DIA)-mass spectrometry (MS) has the potential to provide unbiased, reproducible and quantitative proteome maps - a prerequisite for standardization among experiments. Here, we designed a DIA-based proteomics workflow to profile changes in the abundance of dorsal root ganglia (DRG) proteins in two mouse models of chronic pain, inflammatory and neuropathic. We generated a DRG-specific spectral library containing 3067 DRG proteins, which enables their standardized quantification by means of DIA-MS in any laboratory. Using this resource, we profiled 2526 DRG proteins in each biological replicate of both chronic pain models and respective controls with unprecedented reproducibility. We detected numerous differentially regulated proteins, the majority of which exhibited pain model-specificity. Our approach recapitulates known biology and discovers dozens of proteins that have not been characterized in the somatosensory system before. Functional validation experiments and analysis of mouse pain behaviors demonstrate that indeed meaningful protein alterations were discovered. These results illustrate how the application of DIA-MS can open new avenues to achieve the long-awaited standardization in the molecular dissection of pathologies of the somatosensory system. Therefore, our findings provide a valuable framework to qualitatively extend our understanding of chronic pain and somatosensation. © 2016 by The American Society for Biochemistry and Molecular Biology, Inc.

Variability of nursing care by APR-DRG and by severity of illness in a sample of nine Belgian hospitals.

PubMed

Pirson, Magali; Delo, Caroline; Di Pierdomenico, Lionel; Laport, Nancy; Biloque, Veronique; Leclercq, Pol

2013-10-10

As soon as Diagnosis related Groups (DRG) were introduced in many hospital financing systems, most nursing research revealed that DRG were not very homogeneous with regard to nursing care. However, few studies are based on All Patient refined Diagnosis related Groups (APR-DRGs) and few of them use recent data. Objectives of this study are: (1) to evaluate if nursing activity is homogeneous by APR-DRG and by severity of illness (SOI) (2) to evaluate the outlier's rate associated with the nursing activity and (3) to compare nursing cost homogeneity per DRG and SOI. Study done in 9 Belgian hospitals on a selection of APR-DRG with more than 30 patients (7 638 inpatient stays). The evaluation of the homogeneity is based on coefficients of variation (CV). The 75th percentile + 1.5 × inter-quartile range was used to select high outliers. 25th percentile -1.5 × inter-quartile range was used to select low outliers. Nursing costs per ward were distributed on inpatient stays of each ward following two techniques (the LOS vs. the number of nursing care minutes per stay). The homogeneity of LOS by DRG and by SOI is relatively good (CV: 0.56). The homogeneity of the nursing activity by DRG is less good (CVs between 0.36 and 1.54) and is influenced by nursing activity outliers (high outliers' rate: 5.19%, low outliers' rate: 0.14%). The outlier's rate varies according to the studied variable. The high outliers' rate is higher for nursing activity than for LOS. The homogeneity of nursing costs is higher when costs are based on the LOS of patients than when based on minutes of nursing care (CVs between 0.26 and 1.46 for nursing costs based on LOS and between 0.49 and 2.04 for nursing costs based on minutes of nursing care). It is essential that the calculation of nursing cost by stay and by DRG for hospital financing purposes was based on nursing activity data, that more reflect resources used in wards, and not on LOS data. The only way to obtain this information is the generalization of computerized nursing files.

Variability of nursing care by APR-DRG and by severity of illness in a sample of nine Belgian hospitals

PubMed Central

2013-01-01

Background As soon as Diagnosis related Groups (DRG) were introduced in many hospital financing systems, most nursing research revealed that DRG were not very homogeneous with regard to nursing care. However, few studies are based on All Patient refined Diagnosis related Groups (APR-DRGs) and few of them use recent data. Objectives of this study are: (1) to evaluate if nursing activity is homogeneous by APR-DRG and by severity of illness (SOI) (2) to evaluate the outlier’s rate associated with the nursing activity and (3) to compare nursing cost homogeneity per DRG and SOI. Methods Study done in 9 Belgian hospitals on a selection of APR-DRG with more than 30 patients (7 638 inpatient stays). The evaluation of the homogeneity is based on coefficients of variation (CV). The 75th percentile + 1.5 × inter-quartile range was used to select high outliers. 25th percentile −1.5 × inter-quartile range was used to select low outliers. Nursing costs per ward were distributed on inpatient stays of each ward following two techniques (the LOS vs. the number of nursing care minutes per stay). Results The homogeneity of LOS by DRG and by SOI is relatively good (CV: 0.56). The homogeneity of the nursing activity by DRG is less good (CVs between 0.36 and 1.54) and is influenced by nursing activity outliers (high outliers’ rate: 5.19%, low outliers’ rate: 0.14%). The outlier’s rate varies according to the studied variable. The high outliers’ rate is higher for nursing activity than for LOS. The homogeneity of nursing costs is higher when costs are based on the LOS of patients than when based on minutes of nursing care (CVs between 0.26 and 1.46 for nursing costs based on LOS and between 0.49 and 2.04 for nursing costs based on minutes of nursing care). Conclusions It is essential that the calculation of nursing cost by stay and by DRG for hospital financing purposes was based on nursing activity data, that more reflect resources used in wards, and not on LOS data. The only way to obtain this information is the generalization of computerized nursing files. PMID:24112381

[In vitro interaction of human pancreatic cancer cells and rat dorsal root ganglia: a co-culture model].

PubMed

Liu, Zhi-sheng; Wang, Ye; Li, Qiang; Zhang, Sheng-lin; Shi, Yu-rong

2012-04-01

To establish an in vitro model of perineural invasion (PNI) with co-culture of human pancreatic cancer cells and rat root ganglion, to observe the neurite outgrowth and pancreatic cancer cell proliferation and migration, and to explore the molecular basis of perineural invasion (PNI) of pancreatic cancer. Human pancreatic cancer cell line (MIA PaCa-2) and rat dorsal root ganglion (DRG) were co-cultured in Matrigel matrix to generate the PNI model. The neurite outgrowth, pancreatic cancer cell colony formation, neurite-colony contact and retrograde migration were observed under an inverted microscope. The data were analyzed with the Image-Pro Plus 5.0 system. The proliferative index (PI) was measured by immunohistochemical staining with the Ki-67 antibody. In order to determine the absorbance (A) of the pancreatic cancer cells, MTT assay was used. The apoptotic index (AI) was evaluated by flow cytometry. Neurite outgrowth was stimulated in the presence of pancreatic cancer cells. After 72 hours of the co-culture, MIA PaCa colonies co-cultured with DRG exhibited a significantly larger colony area (242.83 ± 4.92) than that of the control (182.50 ± 5.39, P < 0.001). In the MIA PaCa-2/DRG co-culture system, the neurites exhibited a trend of growing towards the pancreatic cancer cell colony. However, the pancreatic cancer cells showed a trend of retrogradely migrating to the DRG along the neurite outgrowth, when MIA PaCa-2 colonies touched the DRG. The positive rate of Ki-67 nuclear antigen was significantly higher than in the co-culture group. The PI value was higher in the experimental group (12.80%) than that in the control group (6.81%, P < 0.01). The MTT assay showed that proliferation of the pancreatic cancer cells was more active than that in the control group. Flow cytometry analysis showed that the apoptosis rate of the pancreatic cancer cell was 2.46%, significantly lower than that of the control group (4.89%, P < 0.001). An in vitro co-culture model of rat dorsal root ganglion and human pancreatic cancer cell line is successfully established in this study. This MIA PaCa-2/DRG co-culture system demonstrates that the neural-pancreatic carcinoma cell interaction is a mutually beneficial process for the growth of neurites and pancreatic carcinoma cells. The pancreatic cancer cells show a trend of migrating to the DRG along the neurite outgrowth.

[Diagnosis related groups in stroke treatment. An analysis from the stroke data bank of the German Stroke Foundation].

PubMed

Weimar, C; Stausberg, J; Kraywinkel, K; Wagner, M; Busse, O; Haberl, R L; Diener, H-C

2002-08-02

The upcoming introduction of diagnosis related groups (DRG) as an exclusive base for future calculation of hospital proceeds in Germany requires a thorough analysis of cost data for various diseases. To compare the resulting combined cost weights of the Australian Refined DRG system (AR-DRG) with the proceeds based on actual per-day rates in stroke treatment. Between 1998 and 1999, data from 6520 patients (median age 68 years, 43% women) with acute stroke or transient ischemic attack (TIA) were prospectively documented in 15 departments of Neurology with an acute stroke unit, 9 departments of general Neurology and 6 departments of Internal Medicine. Prior to grouping cases into DRGs, all available data were transferred into ICD-10-SGB-V 2.0 or the Australian procedure system (MBS-Extended). Hospital proceeds for the respective cases were calculated based on per-day rates of the documenting hospitals. The resulting cost weights demonstrate a good homogeneity compared to the length of stay. When introducing the AR-DRG with a uniform base rate in Germany, a relative decrease of hospital proceeds can be expected in Neurology Departments and for treatment of TIAs. Preservation of the existing structure of acute stroke care in Germany requires a supplement to a uniform base rate in Neurology departments.

RNA-Seq Analysis of Human Trigeminal and Dorsal Root Ganglia with a Focus on Chemoreceptors

PubMed Central

Flegel, Caroline; Schöbel, Nicole; Altmüller, Janine; Becker, Christian; Tannapfel, Andrea; Hatt, Hanns; Gisselmann, Günter

2015-01-01

The chemosensory capacity of the somatosensory system relies on the appropriate expression of chemoreceptors, which detect chemical stimuli and transduce sensory information into cellular signals. Knowledge of the complete repertoire of the chemoreceptors expressed in human sensory ganglia is lacking. This study employed the next-generation sequencing technique (RNA-Seq) to conduct the first expression analysis of human trigeminal ganglia (TG) and dorsal root ganglia (DRG). We analyzed the data with a focus on G-protein coupled receptors (GPCRs) and ion channels, which are (potentially) involved in chemosensation by somatosensory neurons in the human TG and DRG. For years, transient receptor potential (TRP) channels have been considered the main group of receptors for chemosensation in the trigeminal system. Interestingly, we could show that sensory ganglia also express a panel of different olfactory receptors (ORs) with putative chemosensory function. To characterize OR expression in more detail, we performed microarray, semi-quantitative RT-PCR experiments, and immunohistochemical staining. Additionally, we analyzed the expression data to identify further known or putative classes of chemoreceptors in the human TG and DRG. Our results give an overview of the major classes of chemoreceptors expressed in the human TG and DRG and provide the basis for a broader understanding of the reception of chemical cues. PMID:26070209

Effects of proinflammatory cytokines on axonal outgrowth from adult rat lumbar dorsal root ganglia using a novel three-dimensional culture system.

PubMed

Kim, Hyunchul; W Caspar, Tyler; Shah, Sameer B; Hsieh, Adam H

2015-08-01

Degeneration of the intervertebral disc is often associated with low back pain and increased infiltration of nerve fibers originating from dorsal root ganglia (DRG). The degenerated disc is also characterized by the presence of proinflammatory cytokines, which may influence axonal outgrowth. Toward an improved understanding of the growth of DRG neurons into compliant extracellular matrices, we developed a novel experimental system to measure axonal outgrowth of adult rat lumbar DRG neurons within three-dimensional (3D) collagen hydrogels and used this system to examine the effects of interleukin 1β (IL-1β) and tumor necrosis factor (TNF)-α treatment. The aim was to investigate the effects of proinflammatory cytokines on 3D neuronal growth into collagen matrices. This was an in vitro study of neurite outgrowth from adult rat lumbar DRG into collagen gels in response to IL-1β and TNF-α. Lumbar DRG were obtained from adult Sprague Dawley rats, bisected to expose cell bodies and placed onto collagen gel constructs prepared in 24-well Transwell inserts. Dorsal root ganglia were then treated with nerve growth factor (NGF)-free Neurobasal media (negative control) or NGF-supplemented media containing 0, 1, and 10 ng/mL of IL-1β and TNF-α. After 7 days, collagen gel-DRG constructs were immunostained for phosphorylated neurofilament, an axonal marker. Simple Neurite Tracer (Fiji/ImageJ) was used to quantify 3D axonal outgrowth from confocal image stacks. Data were analyzed using one-way analysis of variance, with Tukey HSD post hoc correction at a level of p<.05. Immunostaining showed robust axonal outgrowth into collagen gels from all NGF-treated DRG. The negative control demonstrated very few and short neurites. Tumor necrosis factor-α (1 and 10 ng/mL) significantly inhibited axonal outgrowth compared with NGF-only media (p<.026 and p<.02, respectively). After IL-1β treatment, average axon length was 10% lower at 1 ng/mL and 7.5% higher at 10 ng/mL, but these differences were not statistically significant. Among cytokine treatments, however, average axon length in the IL-1β (10 ng/mL) group was significantly higher than that in the other groups (p<.05). A novel 3D collagen gel culture system was used to investigate factors modulating neuronal ingrowth. Our results showed that NGF was necessary to promote neurite growth into collagen gels. In the presence of proinflammatory cytokines, high concentrations of IL-1β induced significantly higher axonal outgrowth than TNF-α and low levels of IL-1β. Copyright © 2015 Elsevier Inc. All rights reserved.

Minimally invasive convection-enhanced delivery of biologics into dorsal root ganglia: validation in the pig model and prospective modeling in humans. Technical note.

PubMed

Pleticha, Josef; Maus, Timothy P; Christner, Jodie A; Marsh, Michael P; Lee, Kendall H; Hooten, W Michael; Beutler, Andreas S

2014-10-01

Dorsal root ganglia (DRG) are critical anatomical structures involved in nociception. Intraganglionic (IG) drug delivery is therefore an important route of administration for novel analgesic therapies. Although IG injection in large animal models is highly desirable for preclinical biodistribution and toxicology studies of new drugs, no method to deliver pharmaceutical agents into the DRG has been reported in any large species. The present study describes a minimally invasive technique of IG agent delivery in domestic swine, one of the most common large animal models. The technique utilizes CT guidance for DRG targeting and a custom-made injection assembly for convection enhanced delivery (CED) of therapeutic agents directly into DRG parenchyma. The DRG were initially visualized by CT myelography to determine the optimal access route to the DRG. The subsequent IG injection consisted of 3 steps. First, a commercially available guide needle was advanced to a position dorsolateral to the DRG, and the dural root sleeve was punctured, leaving the guide needle contiguous with, but not penetrating, the DRG. Second, the custom-made stepped stylet was inserted through the guide needle into the DRG parenchyma. Third, the stepped stylet was replaced by the custom-made stepped needle, which was used for the IG CED. Initial dye injections performed in pig cadavers confirmed the accuracy of DRG targeting under CT guidance. Intraganglionic administration of adeno-associated virus in vivo resulted in a unilateral transduction of the injected DRG, with 33.5% DRG neurons transduced. Transgene expression was also found in the dorsal root entry zones at the corresponding spinal levels. The results thereby confirm the efficacy of CED by the stepped needle and a selectivity of DRG targeting. Imaging-based modeling of the procedure in humans suggests that IG CED may be translatable to the clinical setting.

[Botulinum toxin type A does not affect spontaneous discharge but blocks sympathetic-sensory coupling in chronically compressed rat dorsal root ganglion neurons].

PubMed

Yang, Hong-jun; Peng, Kai-run; Hu, San-jue; Duan, Jian-hong

2007-11-01

To study the effect of botulinum toxin type A (BTXA) on spontaneous discharge and sympathetic- sensory coupling in chronically compressed dorsal root ganglion (DRG) neurons in rats. In chronically compressed rat DRG, spontaneous activities of the single fibers from DRG neurons were recorded and their changes observed after BTAX application on the damaged DGR. Sympathetic modulation of the spontaneous discharge from the compressed DRG neurons was observed by electric stimulation of the lumbar sympathetic trunk, and the changes in this effect were evaluated after intravenous BTXA injection in the rats. Active spontaneous discharges were recorded in the injured DRG neurons, and 47 injured DRG neurons responded to Ca2+-free artificial cerebrospinal fluid but not to BTXA treatment. Sixty-four percent of the neurons in the injured DRG responded to sympathetic stimulation, and this response was blocked by intravenously injection of BTXA. BTXA does not affect spontaneous activities of injured DRG neurons, but blocks sympathetic-sensory coupling in these neurons.

[The DRG responsible physician in trauma and orthopedic surgery. Surgeon, encoder, and link to medical controlling].

PubMed

Ruffing, T; Huchzermeier, P; Muhm, M; Winkler, H

2014-05-01

Precise coding is an essential requirement in order to generate a valid DRG. The aim of our study was to evaluate the quality of the initial coding of surgical procedures, as well as to introduce our "hybrid model" of a surgical specialist supervising medical coding and a nonphysician for case auditing. The department's DRG responsible physician as a surgical specialist has profound knowledge both in surgery and in DRG coding. At a Level 1 hospital, 1000 coded cases of surgical procedures were checked. In our department, the DRG responsible physician who is both a surgeon and encoder has proven itself for many years. The initial surgical DRG coding had to be corrected by the DRG responsible physician in 42.2% of cases. On average, one hour per working day was necessary. The implementation of a DRG responsible physician is a simple, effective way to connect medical and business expertise without interface problems. Permanent feedback promotes both medical and economic sensitivity for the improvement of coding quality.

Neurochemical diversity of afferent neurons that transduce sensory signals from dog ventricular myocardium

PubMed Central

Hoover, Donald B.; Shepherd, Angela V.; Southerland, E. Marie; Armour, J. Andrew; Ardell, Jeffrey L.

2008-01-01

While much is known about the influence of ventricular afferent neurons on cardiovascular function in the dog, identification of the neurochemicals transmitting cardiac afferent signals to central neurons is lacking. Accordingly, we identified ventricular afferent neurons in canine dorsal root ganglia (DRG) and nodose ganglia by retrograde labeling after injecting horseradish peroxidase (HRP) into the anterior right and left ventricles. Primary antibodies from three host species were used in immunohistochemical experiments to simultaneously evaluate afferent somata for the presence of HRP and markers for two neurotransmitters. Only a small percentage (2%) of afferent somata were labeled with HRP. About half of the HRP-identified ventricular afferent neurons in T3 DRG also stained for substance P (SP), calcitonin gene-related peptide (CGRP), or neuronal nitric oxide synthase (nNOS), either alone or with two markers colocalized. Ventricular afferent neurons and the general population of T3 DRG neurons showed the same labeling profiles; CGRP (alone or colocalized with SP) being the most common (30–40% of ventricular afferent somata in T3 DRG). About 30% of the ventricular afferent neurons in T2 DRG displayed CGRP immunoreactivity and binding of the putative nociceptive marker IB4. Ventricular afferent neurons of the nodose ganglia were distinct from those in the DRG by having smaller size and lacking immunoreactivity for SP, CGRP, and nNOS. These findings suggest that ventricular sensory information is transferred to the central nervous system by relatively small populations of vagal and spinal afferent neurons and that spinal afferents use a variety of neurotransmitters. PMID:18558516

Neurochemical diversity of afferent neurons that transduce sensory signals from dog ventricular myocardium.

PubMed

Hoover, Donald B; Shepherd, Angela V; Southerland, E Marie; Armour, J Andrew; Ardell, Jeffrey L

2008-08-18

While much is known about the influence of ventricular afferent neurons on cardiovascular function in the dog, identification of the neurochemicals transmitting cardiac afferent signals to central neurons is lacking. Accordingly, we identified ventricular afferent neurons in canine dorsal root ganglia (DRG) and nodose ganglia by retrograde labeling after injecting horseradish peroxidase (HRP) into the anterior right and left ventricles. Primary antibodies from three host species were used in immunohistochemical experiments to simultaneously evaluate afferent somata for the presence of HRP and markers for two neurotransmitters. Only a small percentage (2%) of afferent somata were labeled with HRP. About half of the HRP-identified ventricular afferent neurons in T(3) DRG also stained for substance P (SP), calcitonin gene-related peptide (CGRP), or neuronal nitric oxide synthase (nNOS), either alone or with two markers colocalized. Ventricular afferent neurons and the general population of T(3) DRG neurons showed the same labeling profiles; CGRP (alone or colocalized with SP) being the most common (30-40% of ventricular afferent somata in T(3) DRG). About 30% of the ventricular afferent neurons in T(2) DRG displayed CGRP immunoreactivity and binding of the putative nociceptive marker IB(4). Ventricular afferent neurons of the nodose ganglia were distinct from those in the DRG by having smaller size and lacking immunoreactivity for SP, CGRP, and nNOS. These findings suggest that ventricular sensory information is transferred to the central nervous system by relatively small populations of vagal and spinal afferent neurons and that spinal afferents use a variety of neurotransmitters.

[Reimbursement of intensive care services in the German DRG system : Current problems and possible solutions].

PubMed

Riessen, R; Hermes, C; Bodmann, K-F; Janssens, U; Markewitz, A

2018-02-01

The reimbursement of intensive care and nursing services in the German health system is based on the diagnosis-related groups (G-DRG) system. Due to the lack of a central hospital planning, the G‑DRG system has become the most important influence on the development of the German health system. Compared to other countries, intensive care in Germany is characterized by a high number of intensive care beds, a low nurse-to-patient ratio, no official definition of the level of care, and a minimal available data set from intensive care units (ICUs). Under the given circumstances, a shortage of qualified intensive care nurses and physicians is currently the largest threat for intensive care in Germany. To address these deficiencies, we suggest the following measures: (1) Integration of ICUs into the levels of care which are currently developed for emergency centers at hospitals. (2) Mandatory collection of structured data sets from all ICUs including quality criteria. (3) A reform of intensive care and nursing reimbursement under consideration of adequate staffing in the individual ICU. (4) Actions to improve ICU staffing and qualification.

The costs of acute readmissions to a different hospital - Does the effect vary across provider types?

PubMed

Møller Dahl, Christian; Planck Kongstad, Line

2017-06-01

Treatment costs are found to vary substantially and systematically within DRGs. Several factors have been shown to contribute to the variation in costs within DRGs. We argue that readmissions might also explain part of the observed variation in costs. A substantial number of all readmissions occur to a different hospital. The change in hospital indicates that a progression of the illness has occurred since the initial hospitalisation. As a result, different-hospital readmissions might be more costly compared to same-hospital admissions. The aim of this paper is twofold. Firstly, to analyse differences in costs between different-hospital readmissions and same-hospital readmissions within the same DRG. Secondly, to investigate whether the effect of different-hospital readmission on costs vary depending of provider type (general versus teaching hospital). We use a rich Danish patient-level administrative data set covering inpatient stays in the period 2008-2010. We exploit the fact that some patients are readmitted within the same DRG and that some of these readmissions occur at different hospitals in a propensity score difference-in-difference design. The estimates are based on a restricted sample of n = 328 patients. Our results show that the costs of different-hospital readmissions are significantly higher relative to the costs of same-hospital readmission (approx. €777). Furthermore, the cost difference is found to be almost twice the size for patients readmitted to a teaching hospital (approx. €1016) (P < 0.10) compared to patients readmitted to a different general hospital (approx. €511) (P < 0.10). The results suggest that hospitals in general face a potential risk by treating different-hospital readmissions, and that the financial consequences are highest among teaching hospitals. If teaching hospitals are not compensated for the additional costs of treating different-hospital readmission patients, they might be unfairly funded under a DRG-based payment scheme. Copyright © 2017 Elsevier Ltd. All rights reserved.

Integrated concurrent utilization quality review, Part one.

PubMed

Caterinicchio, R P

1987-01-01

This article is the first of a two-part series which argues for the concurrent management of the appropriateness, necessity, and quality of patient care. Intensifying scrutiny by the credentialing groups, the PROs and all third-party payors underscores the vital need to implement cost-effective information systems which integrate the departmentalized functions of patient-physician profiling, DRG case-mix analyses, length of stay monitoring, pre-admission/admission and continued stay review, discharge planning, risk management, incident reporting and quality review. In the domain of physician performance regarding admitting and practice patterns, the ability to exercise concurrent utilization-quality review means early detection and prevention of events which would otherwise result in denials of payment and/or compromised patient care. Concurrent utilization-quality review must, by definition, be managerially invasive and focused; hence, it is integral to maintaining the integrity of the services and product lines offered by the provider. In fact, if PPO status is a marketing agenda, then the institutional objectives of cost-effectiveness, productivity, value, and competitiveness can only be achieved through concurrent utilization-quality review.

Diastase induced green synthesis of bilayered reduced graphene oxide and its decoration with gold nanoparticles.

PubMed

Maddinedi, Sireesh Babu; Mandal, Badal Kumar; Patil, Sagar Hindurao; Andhalkar, Vaibhav Vilas; Ranjan, Shivendu; Dasgupta, Nandita

2017-01-01

In this paper, we report an enzyme dependent, green one-pot deoxygenation cum decoration method to synthesize diastase-conjugated reduced graphene oxide (DRG) nanosheets, DRG/gold nanoparticles (DRG/Au) composite. The DRG synthesis was completed in 7h under heating at 90°C on water bath. Selected area electron diffraction (SAED) and Atomic force microscopy (AFM) study has revealed the formation of bilayered reduced graphene oxide sheets. Transmission electron microscopy (TEM) images of DRG/Au composite have shown the uniform decoration of gold nanoparticles (AuNPs) onto the DRG nanosheet surface. Fourier transform infrared spectroscopy (FTIR) and Raman results additionally have shown the functionalization of enzyme molecules onto the DRG nanosheet surface after reduction making it as an effective platform towards the efficient binding of gold nanoparticles. In vitro cytotoxicity studies by MTT assay on A549 and HCT116 cell lines exhibited that the cytotoxicity of the prepared graphene oxide (GO), DRG and DRG/Au is dose dependant. These results have shown that this synthetic method is effective for the production of large scale graphene in a low cost, simple and green method. Since this process avoids the use of hazardous and toxic substances, the produced DRG/Au composites are likely to offer various potential applications in biology and medicine. Copyright © 2016 Elsevier B.V. All rights reserved.

Role of MicroRNA-143 in Nerve Injury-Induced Upregulation of Dnmt3a Expression in Primary Sensory Neurons

PubMed Central

Xu, Bo; Cao, Jing; Zhang, Jun; Jia, Shushan; Wu, Shaogen; Mo, Kai; Wei, Guihua; Liang, Lingli; Miao, Xuerong; Bekker, Alex; Tao, Yuan-Xiang

2017-01-01

Peripheral nerve injury increased the expression of the DNA methyltransferase 3A (Dnmt3a) mRNA and its encoding Dnmt3a protein in injured dorsal root ganglia (DRG). This increase is considered as an endogenous instigator in neuropathic pain genesis through epigenetic silencing of pain-associated genes (such as Oprm1) in injured DRG. However, how DRG DNMT3a is increased following peripheral nerve injury is still elusive. We reported here that peripheral nerve injury caused by the fifth spinal nerve ligation (SNL) downregulated microRNA (miR)-143 expression in injured DRG. This downregulation was required for SNL-induced DRG Dnmt3a increase as rescuing miR-143 downregulation through microinjection of miR-143 mimics into injured DRG blocked the SNL-induced increase in Dnmt3a and restored the SNL-induced decreases in Oprm1 mRNA and its encoding mu opioid receptor (MOR) in injured DRG, impaired spinal cord central sensitization and neuropathic pain, and improved morphine analgesic effects following SNL. Mimicking SNL-induced DRG miR-143 downregulation through DRG microinjection of miR143 inhibitors in naive rats increased the expression of Dnmt3a and reduced the expression of Oprm1 mRNA and MOR in injected DRG and produced neuropathic pain-like symptoms. These findings suggest that miR-143 is a negative regulator in Dnmt3a expression in the DRG under neuropathic pain conditions and may be a potential target for therapeutic management of neuropathic pain. PMID:29170626

What DRGs mean to the patient and the provider.

PubMed

Clifford, J C

1989-01-01

What are the effects of DRGs on patients and providers? I have attempted to provide some insights from my own experience and that of others. But I think we must not lose sight of the fact that it is very difficult to determine the specific effects of DRGs in light of all the other environmental factors that contribute to the intensity of patient services and care provider stress and work load. To what extent does the general aging of the population itself contribute to these issues? People would still be getting older, and chronic disease would continue to increase, even if a prospective payment system using DRGs was not in place. Medical technology has not been capped and the explosion of knowledge still directs much of the medical practice related to increased intensity of care. A financially driven health care system was put into place shortly after the implementation of Medicare, when it became obvious how quickly the costs of health care were rising. In many ways it is impossible to say what the specific effects of the DRG system have been on the patient and the provider. Perhaps it is only a little, but, quite frankly, it does not really feel that way to those who are in the mainstream of providing care.

The effect of misclassification errors on case mix measurement.

PubMed

Sutherland, Jason M; Botz, Chas K

2006-12-01

Case mix systems have been implemented for hospital reimbursement and performance measurement across Europe and North America. Case mix categorizes patients into discrete groups based on clinical information obtained from patient charts in an attempt to identify clinical or cost difference amongst these groups. The diagnosis related group (DRG) case mix system is the most common methodology, with variants adopted in many countries. External validation studies of coding quality have confirmed that widespread variability exists between originally recorded diagnoses and re-abstracted clinical information. DRG assignment errors in hospitals that share patient level cost data for the purpose of establishing cost weights affects cost weight accuracy. The purpose of this study is to estimate bias in cost weights due to measurement error of reported clinical information. DRG assignment error rates are simulated based on recent clinical re-abstraction study results. Our simulation study estimates that 47% of cost weights representing the least severe cases are over weight by 10%, while 32% of cost weights representing the most severe cases are under weight by 10%. Applying the simulated weights to a cross-section of hospitals, we find that teaching hospitals tend to be under weight. Since inaccurate cost weights challenges the ability of case mix systems to accurately reflect patient mix and may lead to potential distortions in hospital funding, bias in hospital case mix measurement highlights the role clinical data quality plays in hospital funding in countries that use DRG-type case mix systems. Quality of clinical information should be carefully considered from hospitals that contribute financial data for establishing cost weights.

Paying a Premium: How Patient Complexity Affects Costs and Profit Margins

PubMed Central

Taheri, Paul A.; Butz, David A.; Greenfield, Lazar J.

1999-01-01

Objective and Background Tertiary medical centers continue to be under extreme pressure to deliver high-complexity care, but paradoxically there is considerable pressure within these institutions to reduce their emphasis on tertiary care and refocus their efforts to develop a more community-like practice. The genesis of this pressure is the perceived profitability of routine surgical activity when compared with more complex care. The purpose of this study is to assess how the total cost and profit (loss) margin can vary for an entire trauma service. The authors also evaluate payments for specific trauma-related diagnostic-related groups (DRGs) and analyze how hospital margins were affected based on mortality outcome. Materials and Methods The authors analyzed the actual cost of all trauma discharges (n = 692) at their level I trauma center for fiscal year 1997. Data were obtained from the trauma registry and the hospital cost accounting system. Total cost was defined as the sum of the variable, fixed, and indirect costs associated with each patient. Margin was defined as expected payments minus total cost. The entire population and all DRGs with 10 or more patients were stratified based on survival outcome, Injury Severity Score, insurance status, and length of stay. The mean total costs for survivors and nonsurvivors within these various categories and their margins were evaluated. Results The profit margin on nonsurvivors was $5898 greater than for survivors, even though the mean total cost for nonsurvivors was $28,821 greater. Within the fixed fee arrangement, approximately 44% of transfers had a negative margin. Both survivors and nonsurvivors become increasingly profitable out to 20 days and subsequently become unprofitable beyond 21 days, but nonsurvivors were more profitable than survivors. Conclusions There is a wide variance in both the costs and margins within trauma-related DRGs. The DRG payment system disproportionately reimburses providers for nonsurvivors, even though on average they are more costly. Because payers are likely to engage in portfolio management, patients can be transferred between hospitals based on the contractual relationship between the payer and the provider. This payment system potentially allows payers to act strategically, sending relatively low-cost patients to hospitals where they use fee-for-service reimbursement and high-cost patients to hospitals where their reimbursement is contractually capped. Although specific to the authors’ trauma center and its payer mix, these data demonstrate the profitability of maintaining a level I trauma center and preserving the mission of delivering care to the severely injured. PMID:10363894

[Effect of high-fat diet on expression of transient receptor potential vanilloid 1 in respiratory tract and dorsal root ganglion of mice].

PubMed

Zhu, Lian; Xu, Zhi-Liang

2017-07-01

To investigate the effect of high-fat diet on the expression of transient receptor potential vanilloid 1 (TRPV1) in the respiratory system and the dorsal root ganglion (DRG) of mice, as well as its effect on the excitability of sensory neurons. A total of 20 C57BL/6 mice were randomly divided into normal-diet (ND) group and high-fat diet (HFD) group, with 10 mice in each group. The mice were given corresponding diets and body weights were monitored. After 7 weeks of feeding, lung tissue, bronchial tissue, and DRG at thoracic segments 3-4 were collected and immunohistochemical staining was performed. A patch clamp was used to measure the number of action potentials and TRPV1 current intensity in the DRG. After 7 weeks of feeding, the HFD group had significantly greater mean weight gain than the ND group (6.4±2.6 g vs 2.3±0.5 g; P<0.001). The HFD group had significantly higher expression of TRPV1 in the bronchus, pulmonary alveoli, and DRG than the ND group (P<0.05). Compared with the ND group, the HFD group had significant increases in the TRPV1 current intensity and number of action potentials in the DRG (P<0.05). High-fat diet induces a significant increase in body weight and leads to high expression of TRPV1 and high excitability in the respiratory system and the peripheral sensory neurons. This suggests that TRPV1 may be an important factor in the physiopathological mechanisms of bronchial hyperresponsiveness.

[Development of the German diagnosis-related groups (G-DRG) for ophthalmology from 2004 to 2012].

PubMed

Schargus, M; Gass, P; Neubauer, A; Kotas, M

2014-04-01

In 2003 the German diagnosis-related groups (G-DRG) were introduced for reimbursement of inpatient treatment. The aim of this study was to analyze the development of G-DRGs in ophthalmology in Germany (MDC02) from 2004 to 2012 by means of data from the Institute for the Reimbursement System in Hospitals (InEK). The data regarding costs, cost weighting and mean length of stay (LOS) from the G-DRG reports of the InEK from 2004 to 2012 in 9 representative surgical and non-surgical ophthalmological treatment case groups were analyzed. Differences in the coding system as well as alterations between the G-DRGs over the course of time were taken into consideration. The cost weightings were calculated taking the year 2004 as the baseline and are presented in the form of graphs. The selected cases cover 54% of all G-DRG cases used by the InEK for G-DRG calculations. For 6 out of the 9 case groups there was a cost/reimbursement reduction by nearly one third of the calculated costs by InEK from 2004 to 2012. Only one case group showed an increase in costs by 23% which can be explained by alterations in graft costs in this case group. The mean LOS decreased over the time period in the 9 groups investigated by up to 40% and on average by -22.3%. The annually calculated costs of the InEK directly influence the calculation of the cost weightings and reimbursement and are therefore important for every hospital. During the time period analyzed a high reduction in costs and LOS in the majority of the analyzed case groups were found.

Co-culture of osteocytes and neurons on a unique patterned surface.

PubMed

Boggs, Mary E; Thompson, William R; Farach-Carson, Mary C; Duncan, Randall L; Beebe, Thomas P

2011-12-01

Neural and skeletal communication is essential for the maintenance of bone mass and transmission of pain, yet the mechanism(s) of signal transduction between these tissues is unknown. The authors established a novel system to co-culture murine long bone osteocyte-like cells (MLO-Y4) and primary murine dorsal root ganglia (DRG) neurons. Assessment of morphology and maturation marker expression on perlecan domain IV peptide (PlnDIV) and collagen type-1 (Col1) demonstrated that PlnDIV was an optimal matrix for MLO-Y4 culture. A novel matrix-specificity competition assay was developed to expose these cells to several extracellular matrix proteins such as PlnDIV, Col1, and laminin (Ln). The competition assay showed that approximately 70% of MLO-Y4 cells preferred either PlnDIV or Col1 to Ln. To co-culture MLO-Y4 and DRG, we developed patterned surfaces using micro-contact printing to create 40 μm × 1 cm alternating stripes of PlnDIV and Ln or PlnDIV and Col1. Co-culture on PlnDIV/Ln surfaces demonstrated that these matrix molecules provided unique cues for each cell type, with MLO-Y4 preferentially attaching to the PlnDIV lanes and DRG neurons to the Ln lanes. Approximately 80% of DRG were localized to Ln. Cellular processes from MLO-Y4 were closely associated with axonal extensions of DRG neurons. Approximately 57% of neuronal processes were in close proximity to nearby MLO-Y4 cells at the PlnDIV-Ln interface. The surfaces in this new assay provided a unique model system with which to study the communication between osteocyte-like cells and neurons in an in vitro environment.

Chlorpyrifos and chlorpyrifos-oxon inhibit axonal growth by interfering with the morphogenic activity of acetylcholinesterase

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yang Dongren; Howard, Angela; Bruun, Donald

2008-04-01

A primary role of acetylcholinesterase (AChE) is regulation of cholinergic neurotransmission by hydrolysis of synaptic acetylcholine. In the developing nervous system, however, AChE also functions as a morphogenic factor to promote axonal growth. This raises the question of whether organophosphorus pesticides (OPs) that are known to selectively bind to and inactivate the enzymatic function of AChE also interfere with its morphogenic function to perturb axonogenesis. To test this hypothesis, we exposed primary cultures of sensory neurons derived from embryonic rat dorsal root ganglia (DRG) to chlorpyrifos (CPF) or its oxon metabolite (CPFO). Both OPs significantly decreased axonal length at concentrationsmore » that had no effect on cell viability, protein synthesis or the enzymatic activity of AChE. Comparative analyses of the effects of CPF and CPFO on axonal growth in DRG neurons cultured from AChE nullizygous (AChE{sup -/-}) versus wild type (AChE{sup +/+}) mice indicated that while these OPs inhibited axonal growth in AChE{sup +/+} DRG neurons, they had no effect on axonal growth in AChE{sup -/-} DRG neurons. However, transfection of AChE{sup -/-} DRG neurons with cDNA encoding full-length AChE restored the wild type response to the axon inhibitory effects of OPs. These data indicate that inhibition of axonal growth by OPs requires AChE, but the mechanism involves inhibition of the morphogenic rather than enzymatic activity of AChE. These findings suggest a novel mechanism for explaining not only the functional deficits observed in children and animals following developmental exposure to OPs, but also the increased vulnerability of the developing nervous system to OPs.« less

The impact of casemix on the care of the elderly.

PubMed

Finnegan, T P

2001-06-01

The Australian Health care system is a mix of public and private provision. The Federal Government funds medical care and the pharmaceutical benefit scheme while the State Governments are responsible for funding the public hospitals. Geriatric Medical care is provided in the public hospital system. The Australian DRG system has evolved to more adequately explain illness severity by a greater use of the complications and comorbidities. The structure of the Sub-Acute and Non-Acute Patient (SNAP) classification is outlined. While it is anecdotally said that the introduction of DRG-based funding is detrimental to the elderly, the published evidence does not support this. The potential benefits of a casemix system are discussed.

Investigation of the novel attributes in double recessed gate SiC MESFETs at drain side

NASA Astrophysics Data System (ADS)

Orouji, Ali A.; Razavi, S. M.; Ebrahim Hosseini, Seyed; Amini Moghadam, Hamid

2011-11-01

In this paper, the potential impact of drain side-double recessed gate (DS-DRG) on silicon carbide (SiC)-based metal semiconductor field effect transistors (MESFETs) is studied. We investigate the device performance focusing on breakdown voltage, threshold voltage, drain current and dc output conductance with two-dimensional and two-carrier device simulation. Our simulation results demonstrate that the channel thickness under the gate in the drain side is an important factor in the breakdown voltage. Also, the positive shift in the threshold voltage for the DS-DRG structure is larger in comparison with that for the source side-double recessed gate (SS-DRG) SiC MESFET. The saturated drain current for the DS-DRG structure is larger compared to that for the SS-DRG structure. The maximum dc output conductance in the DS-DRG structure is smaller than that in the SS-DRG structure.

42 CFR 412.515 - LTC-DRG weighting factors.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false LTC-DRG weighting factors. 412.515 Section 412.515 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE...-Term Care Hospitals § 412.515 LTC-DRG weighting factors. For each LTC-DRG, CMS assigns an appropriate...

Somatosensory neuron types identified by high-coverage single-cell RNA-sequencing and functional heterogeneity

PubMed Central

Li, Chang-Lin; Li, Kai-Cheng; Wu, Dan; Chen, Yan; Luo, Hao; Zhao, Jing-Rong; Wang, Sa-Shuang; Sun, Ming-Ming; Lu, Ying-Jin; Zhong, Yan-Qing; Hu, Xu-Ye; Hou, Rui; Zhou, Bei-Bei; Bao, Lan; Xiao, Hua-Sheng; Zhang, Xu

2016-01-01

Sensory neurons are distinguished by distinct signaling networks and receptive characteristics. Thus, sensory neuron types can be defined by linking transcriptome-based neuron typing with the sensory phenotypes. Here we classify somatosensory neurons of the mouse dorsal root ganglion (DRG) by high-coverage single-cell RNA-sequencing (10 950 ± 1 218 genes per neuron) and neuron size-based hierarchical clustering. Moreover, single DRG neurons responding to cutaneous stimuli are recorded using an in vivo whole-cell patch clamp technique and classified by neuron-type genetic markers. Small diameter DRG neurons are classified into one type of low-threshold mechanoreceptor and five types of mechanoheat nociceptors (MHNs). Each of the MHN types is further categorized into two subtypes. Large DRG neurons are categorized into four types, including neurexophilin 1-expressing MHNs and mechanical nociceptors (MNs) expressing BAI1-associated protein 2-like 1 (Baiap2l1). Mechanoreceptors expressing trafficking protein particle complex 3-like and Baiap2l1-marked MNs are subdivided into two subtypes each. These results provide a new system for cataloging somatosensory neurons and their transcriptome databases. PMID:26691752

CFTR mediates noradrenaline-induced ATP efflux from DRG neurons.

PubMed

Kanno, Takeshi; Nishizaki, Tomoyuki

2011-09-24

In our earlier study, noradrenaline (NA) stimulated ATP release from dorsal root ganglion (DRG) neurons as mediated via β(3) adrenoceptors linked to G(s) protein involving protein kinase A (PKA) activation, to cause allodynia. The present study was conducted to understand how ATP is released from DRG neurons. In an outside-out patch-clamp configuration from acutely dissociated rat DRG neurons, single-channel currents, sensitive to the P2X receptor inhibitor PPADS, were evoked by approaching the patch-electrode tip close to a neuron, indicating that ATP is released from DRG neurons, to activate P2X receptor. NA increased the frequency of the single-channel events, but such NA effect was not found for DRG neurons transfected with the siRNA to silence the cystic fibrosis transmembrane conductance regulator (CFTR) gene. In the immunocytochemical study using acutely dissociated rat DRG cells, CFTR was expressed in neurons alone, but not satellite cells, fibroblasts, or Schwann cells. It is concluded from these results that CFTR mediates NA-induced ATP efflux from DRG neurons as an ATP channel.

Functional interaction of TRPV4 channel protein with annexin A2 in DRG.

PubMed

Ning, Liping; Wang, Chuanwei; Ding, Xinli; Zhang, Yang; Wang, Xuping; Yue, Shouwei

2012-09-01

Transient receptor potential vanilloid 4 (TRPV4) is a Ca(2+)-permeable, non-selective cation channel that is involved in the transmission of pain signals mediated by dorsal root ganglion (DRG). Annexin A2 belongs to a class of membrane-binding proteins that plays an important role in the regulation of ion channels. Nevertheless, little is known about the interaction between them in DRG. In this paper, we evaluated the functional interaction of TRPV4 with annexin A2 in DRG. We have used immunocytochemistry and co-immunoprecipitation assays to investigate the interaction between annexin A2 and TRPV4 in DRG. The role of annexin A2 in the regulation of TRPV4 activity in DRG was further verified by measurement of intracellular free calcium concentrations ([Ca(2+)](i)) and substance P (SP) release. First, annexin A2 was showed partial co-localization with TRPV4 in DRG neurons. Then, annexin A2 and TRPV4 were co-precipitated with each other in DRG lysates. Furthermore, the downregulation of annexin A2 using specific small interfering RNA significantly inhibited Ca(2+) influx and SP mediated by TRPV4. Our results provide evidence that annexin A2 is associated with TRPV4 and regulates TRPV4-mediated Ca(2+) influx and SP release in DRG neurons. The objective of this work is to determine the influence of annexin A2 on TRPV4 in DRG neurons, which may be the basis for treatment of pain relief.

Functional, electrophysiological recoveries of rats with sciatic nerve lesions following transplantation of elongated DRG cells.

PubMed

Dayawansa, Samantha; Zhang, Jun; Shih, Chung-Hsuan; Tharakan, Binu; Huang, Jason H

2016-04-01

Functional data are essential when confirming the efficacy of elongated dorsal root ganglia (DRG) cells as a substitute for autografting. We present the quantitative functional motor, electrophysiological findings of engineered DRG recipients for the first time. Elongated DRG neurons and autografts were transplanted to bridge 1-cm sciatic nerve lesions of Sprague Dawley (SD) rats. Motor recoveries of elongated DRG recipients (n=9), autograft recipients (n=9), unrepaired rats (n=9) and intact rats (n=6) were investigated using the angle board challenge test following 16 weeks of recovery. Electrophysiology studies were conducted to assess the functional recovery at 16 weeks. In addition, elongated DRGs were subjected to histology assessments. At threshold levels (35° angle) of the angle board challenge test, the autograft recipients', DRG recipients' and unrepaired group's performances were equal to each other and were less than the intact group (p<0.05). However, during the subthreshold (30°) angle board challenge test, the elongated DRG recipients' performance was similar to both the intact group and the autograft nerve recipients, and was better (p<0.05) than the unrepaired group. The autograft recipients' performance was similar to the unrepaired group and was significantly different (p<0.05) compared with the performance of the intact group. During electrophysiological testing, the rats with transplanted engineered DRG constructs had intact signal transmission when recorded over the lesion, while the unrepaired rats did not. It was observed that elongated DRG neurons closely resembled an autograft during histological assessments. Performances of autograft and elongated DRG construct recipients were similar. Elongated DRG neurons should be further investigated as a substitute for autografting.

Inhibition of sympathetic sprouting in CCD rats by lacosamide.

PubMed

Wang, Yuying; Huo, Fuquan

2018-05-14

Early hyperexcitability activity of injured nerve/neuron is critical for developing sympathetic nerve sprouting within dorsal root ganglia (DRG). Since lacosamide (LCM), an anticonvulsant, inhibits Na + channel. The present study tried to test the potential effect of LCM on inhibiting sympathetic sprouting in vivo. LCM (50 mg/kg) was daily injected intraperitoneally into rats subjected to chronic compression DRG (CCD), an animal model of neuropathic pain that exhibits sympathetic nerve sprouting, for the 1st 7 days after injury. Mechanical sensitivity was tested from day 3 to day 18 after injury, and then DRGs were removed off. Immunohistochemical staining for tyrosine hydroxylase (TH) was examined to observe sympathetic sprouting, and patch-clamp recording was performed to test the excitability and Na + current of DRG neurons. Early systemic LCM treatment significantly reduced TH immunoreactivity density in injured DRG, lowered the excitability level of injured DRG neurons, and increased paw withdrawal threshold (PWT). These effects on reducing sympathetic sprouting, inhibiting excitability and suppressing pain behavior were observed 10 days after the end of early LCM injection. In vitro 100 μM LCM instantly reduced the excitability of CCD neurons via inhibiting Na + current and reducing the amplitude of AP. All the findings suggest, for the first time, that early administration of LCM inhibited sympathetic sprouting and then alleviated neuropathic pain. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Predictable pulsatile release of tramadol hydrochloride for chronotherapeutics of arthritis.

PubMed

Dabhi, Chandu; Randale, Shivsagar; Belgamwar, Veena; Gattani, Surendra; Tekade, Avinash

2010-07-01

The present investigation deals with the development of a pH and time-dependent press-coated pulsatile drug delivery system for delivering drugs into the colon. The system consists of a drug containing core, coated by a combination of natural polymer Delonix regia gum (DRG) and hydroxypropyl methylcellulose (HPMC K4M) in various proportions, which controls the onset of release. The whole system was coated with methacrylic acid copolymers, which not only prevents the drug release in the stomach, but also prolongs the lag time. Tramadol HCl was used as a model drug and varying combinations of DRG and HPMC K4M were used to achieve the desired lag time before rapid and complete release of the drug in the colon. It was observed that the lag time depends on the coating ratio of DRG to HPMC and also on press coating weight. Drug release was found to be increased by 15-30% in the presence of colonic microbial flora. The results showed the capability of the system in achieving pulsatile release for a programmable period of time and pH-dependent release to attain colon-targeted delivery.

[Evaluation of the appropriateness of hospital admissions using the iso-gravity classification systems APR-DRG and Disease Staging and the Italian version of Appropriateness Evaluation Protocol (AEP)].

PubMed

D'Andrea, G; Capalbo, G; Volpe, M; Marchetti, M; Vicentini, F; Capelli, G; Cambieri, A; Cicchetti, A; Ricciardi, G; Catananti, C

2006-01-01

Our main purpose was to evaluate the organizational appropriateness of admissions made in a university hospital, by comparing two iso-gravity classification systems, APR-DRG and Disease Staging, with the Italian version of AEP (PRUO). Our analysis focused on admissions made in 2001, related to specific Diagnosis Related Groups (DRGs), which, according an Italian Law, would be considered at high risk of inappropriateness, if treated as ordinary admissions. The results obtained by using the 2 classification systems did not show statistically significant differences with respect to the total number of admissions. On the other hand, some DRGs showed statistically significant differences due to different algorithms of attribution of the severity levels used by the two systems. For almost all of the DRGs studied, the AEP-based analysis of a sample of medical records showed an higher number of inappropriate admissions in comparison with the number expected by iso-gravity classification methods. The difference is possibly due to the percentage limits of tolerability fixed by the Law for each DRG. Therefore, the authors suggest an integrated use of the two methods to evaluate organizational appropriateness of hospital admissions.

[Comparison between the Austrian and German DRG systems in hand surgery].

PubMed

Lotter, O; Jaminet, P; Schwarzach, S; Schaller, H E

2013-02-01

Diagnosis-Related Groups (DRG) are a patient classification system grouping related types of patients treated to the resources they consumed. In this analysis, we compared the Austrian and the German DRG systems. The 15 most common hand surgical diagnoses and their corresponding operative treatment were transferred into the Austrian system. Thus, the length of stay and the reimbursement of both countries could be obtained and compared. The mean values and the median values of the upper and lower thresholds of length of stay as well as the average length of stay were all lower in Austria compared to Germany. Reimbursement in Germany was higher in 13 of 19 cases. Total proceeds amounted to 1.67 million in the German and 1.70 million in the Austrian health care system. Considering the purchasing power applying consumer prize parities, the difference of reimbursement between the countries rose to 130,000 which equals a difference of almost 8%. Reimbursement of the top 15 diagnoses in hand surgery in Austria is 8% higher than in Germany. Except for one case, mean values as well as upper and lower thresholds of length of stay are considerably shorter in Austria. Comparison of international data to refine a national compensation system is advocated.

42 CFR 478.15 - QIO review of changes resulting from DRG validation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false QIO review of changes resulting from DRG validation... review of changes resulting from DRG validation. (a) General rules. (1) A provider or practitioner dissatisfied with a change to the diagnostic or procedural coding information made by a QIO as a result of DRG...

42 CFR 476.94 - Notice of QIO initial denial determination and changes as a result of a DRG validation.

Code of Federal Regulations, 2014 CFR

2014-10-01

... changes as a result of a DRG validation. 476.94 Section 476.94 Public Health CENTERS FOR MEDICARE... DRG validation. (a) Notice of initial denial determination—(1) Parties to be notified. A QIO must... of identification; (vi) For retrospective review, (excluding DRG validation and post procedure review...

Differential renormalization-group generators for static and dynamic critical phenomena

NASA Astrophysics Data System (ADS)

Chang, T. S.; Vvedensky, D. D.; Nicoll, J. F.

1992-09-01

The derivation of differential renormalization-group (DRG) equations for applications to static and dynamic critical phenomena is reviewed. The DRG approach provides a self-contained closed-form representation of the Wilson renormalization group (RG) and should be viewed as complementary to the Callan-Symanzik equations used in field-theoretic approaches to the RG. The various forms of DRG equations are derived to illustrate the general mathematical structure of each approach and to point out the advantages and disadvantages for performing practical calculations. Otherwise, the review focuses upon the one-particle-irreducible DRG equations derived by Nicoll and Chang and by Chang, Nicoll, and Young; no attempt is made to provide a general treatise of critical phenomena. A few specific examples are included to illustrate the utility of the DRG approach: the large- n limit of the classical n-vector model (the spherical model), multi- or higher-order critical phenomena, and crit ical dynamics far from equilibrium. The large- n limit of the n-vector model is used to introduce the application of DRG equations to a well-known example, with exact solution obtained for the nonlinear trajectories, generating functions for nonlinear scaling fields, and the equation of state. Trajectory integrals and nonlinear scaling fields within the framework of ɛ-expansions are then discussed for tricritical crossover, and briefly for certain aspects of multi- or higher-order critical points, including the derivation of the Helmholtz free energy and the equation of state. The discussion then turns to critical dynamics with a development of the path integral formulation for general dynamic processes. This is followed by an application to a model far-from-equilibrium system that undergoes a phase transformation analogous to a second-order critical point, the Schlögl model for a chemical instability.

Potential loss of revenue due to errors in clinical coding during the implementation of the Malaysia diagnosis related group (MY-DRG®) Casemix system in a teaching hospital in Malaysia.

PubMed

Zafirah, S A; Nur, Amrizal Muhammad; Puteh, Sharifa Ezat Wan; Aljunid, Syed Mohamed

2018-01-25

The accuracy of clinical coding is crucial in the assignment of Diagnosis Related Groups (DRGs) codes, especially if the hospital is using Casemix System as a tool for resource allocations and efficiency monitoring. The aim of this study was to estimate the potential loss of income due to an error in clinical coding during the implementation of the Malaysia Diagnosis Related Group (MY-DRG ® ) Casemix System in a teaching hospital in Malaysia. Four hundred and sixty-four (464) coded medical records were selected, re-examined and re-coded by an independent senior coder (ISC). This ISC re-examined and re-coded the error code that was originally entered by the hospital coders. The pre- and post-coding results were compared, and if there was any disagreement, the codes by the ISC were considered the accurate codes. The cases were then re-grouped using a MY-DRG ® grouper to assess and compare the changes in the DRG assignment and the hospital tariff assignment. The outcomes were then verified by a casemix expert. Coding errors were found in 89.4% (415/424) of the selected patient medical records. Coding errors in secondary diagnoses were the highest, at 81.3% (377/464), followed by secondary procedures at 58.2% (270/464), principal procedures of 50.9% (236/464) and primary diagnoses at 49.8% (231/464), respectively. The coding errors resulted in the assignment of different MY-DRG ® codes in 74.0% (307/415) of the cases. From this result, 52.1% (160/307) of the cases had a lower assigned hospital tariff. In total, the potential loss of income due to changes in the assignment of the MY-DRG ® code was RM654,303.91. The quality of coding is a crucial aspect in implementing casemix systems. Intensive re-training and the close monitoring of coder performance in the hospital should be performed to prevent the potential loss of hospital income.

[Quality assurance in coding expertise of hospital cases in the German DRG system. Evaluation of inter-rater reliability in MDK expertise].

PubMed

Huber, H; Brambrink, M; Funk, R; Rieger, M

2012-10-01

The purpose of this study was to evaluate differences in the D-DRG results of a hospital case by 2 independently coding MKD raters. Calculation of the 2-inter-rater reliability was performed by examination of the coding of individual hospital cases. The reasons for the non-agreement of the expert evaluations and suggestions to improve the process are discussed. From the expert evaluation pool of the MDK-WL a random sample of 0.7% of the 57,375 expertises was taken. Distribution equality with the basic total was tested by the χ² test or, respectively, Fisher's exact test. For the total of 402 individual hospital cases, the G-DRG case sums of 2 experts of the MDK were determined independently and the results checked for each individual case for agreement or non-agreement. The corresponding confidence intervals with standard errors were analysed to test if certain major diagnosis categories (MDC) were statistically significantly more affected by differing expertise results than others. In 280 of the total 402 tested hospital cases, the 2 MDK raters independently reached the same G-DRG results; in 122 cases the G-DRG case sums determined by the 2 raters differed (agreement 70%; CI 65.2-74.1). Different DRG results between the 2 experts occurred regularly in the entire MDC spectrum. No MDC chapter in which significant differences between the 2 raters arose could be identified. The results of our study demonstrate an almost 70% agreement in the evaluation of hospital cost accounts by 2 independently operating MDK. This result leaves room for improvement. Optimisation potentials can be recognised on the basis of the results. Potential for improvement was established in combination with regular further training and the expansion of binding internal code recommendations as well as exchange of code-relevant information among experts in internal forums. The presented model is in principle suitable for cross-border examinations within the MDK system with the advantage that further trends could be uncovered by more variety and larger numbers of the randomly selected cases. © Georg Thieme Verlag KG Stuttgart · New York.

Antidepressant Imipramine Protects Bupivacaine-Induced Neurotoxicity in Dorsal Root Ganglion Neurons Through Coactivation of TrkA and TrkB.

PubMed

Guo, Jianrong; Wang, Huan; Tao, Qiang; Sun, Shiyu; Liu, Li; Zhang, Jianping; Yang, Dawei

2017-11-01

In our work, we used an in vitro culture model to investigate whether antidepressant imipramine (Ip) may protect bupivacaine (Bv)-induced neurotoxicity in mouse dorsal root ganglion (DRG). Adult mouse DRG was treated with 5 mM Bv in vitro to induce neurotoxicity. DRG was then pre-treated with Ip, prior to Bv, to examine its effects on protecting Bv-induced DRG apoptosis and neurite degeneration. Ip-induced dynamic changes in Trk receptors, including TrkA/B/C and phosphor (p-)TrkA/B/C, were examined by qPCR and Western blot. TrkA and TrkB were inhibited by siRNAs to further investigate their functional role in Ip- and Bv-treated DRG. Ip protected Bv-induced apoptosis and neurite loss in DRG. Ip did not alter TrkA/B/C expressions, whereas significantly augmented protein productions of p-TrkA and p-TrkB, but not p-TrkC. SiRNA-mediated TrkA or TrkB downregulation inhibited Trk receptors, and reduced p-TrkA and p-TrkB in DRG. TrkA or TrkB downregulation alone had no effect on Ip-induced protection in Bv-injured DRG. However, co-inhibition of TrkA and TrkB significantly ameliorated the protective effect of Ip on Bv-induced apoptosis and neurite loss in DRG. Imipramine protected bupivacaine-induced neurotoxicity in DRG, likely via the co-activation of TrkA and TrkB signaling pathways. J. Cell. Biochem. 118: 3960-3967, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

[Substance P and/or calcitonin gene-related peptide immunoreactive neurons in dorsal root ganglia possibly involved in the transmission of nociception in rat penile frenulum].

PubMed

Wu, Zhong-Min; Ni, Jing-Jing; Ling, Shu-Cai

2007-12-01

To study the relationship between substance P (SP) and/or calcitonin gene-related peptide (CGRP) immunoreactive neurons in dorsal root ganglia (DRG) and the transmission of nociception in the penile frenulum of rats. The fluoro-gold (FG) retrograde tracing method was used to trace the origin of nerve terminals in the penile frenulum of rats. And SP and/or CGRP immunofluorescence labeling was employed to detect the distribution of SP and/or CGRP immunoreactive neurons in DRG. FG retrograde tracing showed that the FG retrolabeled neurons were localized in L6-DRG and S1-DRG. SP and/or CGRP immunofluorescence labeling indicated that a large number of DRG neurons were SP- and CGRP-immunoreactive, different in size, bright red and bright green respectively in color, and arranged in rows or spots among nerve bundles. All the FG/SP and FG/CGRP double-labeled neurons were medium or small-sized. One third of the FG-labeled neurons were SP-immunoreactive, and a half of them CGRP-immunoreactive in L6-DRG and S1-DRG respectively. The FG/SP/CGRP-labeled neurons accounted for one fifth of the FG retro labeled neurons. SP- and CGRP-immunoreactive neurons in L6-DRG and SI-DRG of rats may be involved in the transmission of nociception in rat penile frenulum.

Effective gene expression in the rat dorsal root ganglia with a non-viral vector delivered via spinal nerve injection

PubMed Central

Chang, Ming-Fong; Hsieh, Jung-Hsien; Chiang, Hao; Kan, Hung-Wei; Huang, Cho-Min; Chellis, Luke; Lin, Bo-Shiou; Miaw, Shi-Chuen; Pan, Chun-Liang; Chao, Chi-Chao; Hsieh, Sung-Tsang

2016-01-01

Delivering gene constructs into the dorsal root ganglia (DRG) is a powerful but challenging therapeutic strategy for sensory disorders affecting the DRG and their peripheral processes. The current delivery methods of direct intra-DRG injection and intrathecal injection have several disadvantages, including potential injury to DRG neurons and low transfection efficiency, respectively. This study aimed to develop a spinal nerve injection strategy to deliver polyethylenimine mixed with plasmid (PEI/DNA polyplexes) containing green fluorescent protein (GFP). Using this spinal nerve injection approach, PEI/DNA polyplexes were delivered to DRG neurons without nerve injury. Within one week of the delivery, GFP expression was detected in 82.8% ± 1.70% of DRG neurons, comparable to the levels obtained by intra-DRG injection (81.3% ± 5.1%, p = 0.82) but much higher than those obtained by intrathecal injection. The degree of GFP expression by neurofilament(+) and peripherin(+) DRG neurons was similar. The safety of this approach was documented by the absence of injury marker expression, including activation transcription factor 3 and ionized calcium binding adaptor molecule 1 for neurons and glia, respectively, as well as the absence of behavioral changes. These results demonstrated the efficacy and safety of delivering PEI/DNA polyplexes to DRG neurons via spinal nerve injection. PMID:27748450

Amitriptyline Activates TrkA to Aid Neuronal Growth and Attenuate Anesthesia-Induced Neurodegeneration in Rat Dorsal Root Ganglion Neurons.

PubMed

Zheng, Xiaochun; Chen, Feng; Zheng, Ting; Huang, Fengyi; Chen, Jianghu; Tu, Wenshao

2016-05-01

Tricyclic antidepressant amitriptyline (AM) has been shown to exert neurotrophic activity on neurons. We thus explored whether AM may aid the neuronal development and protect anesthesia-induced neuro-injury in young spinal cord dorsal root ganglion (DRG) neurons.The DRG explants were prepared from 1-day-old rats. The effect of AM on aiding DRG neural development was examined by immunohistochemistry at dose-dependent manner. AM-induced changes in gene and protein expressions, and also phosphorylation states of tyrosine kinases receptor A (TrkA) and B (TrkB) in DRG, were examined by quantitative real-time polymerase chain reaction and western blot. The effect of AM on attenuating lidocaine-induced DRG neurodegeneration was examined by immunohistochemistry, and small interfering RNA (siRNA)-mediated TrkA/B down-regulation.Amitriptyline stimulated DRG neuronal development in dose-dependent manner, but exerted toxic effect at concentrations higher than 10 M. AM activated TrkA in DRG through phosphorylation, whereas it had little effect on TrkB-signaling pathway. AM reduced lidocaine-induced DRG neurodegeneration by regenerating neurites and growth cones. Moreover, the neuroprotection of AM on lidocaine-injured neurodegeneration was blocked by siRNA-mediated TrkA down-regulation, but not by TrkB down-regulation.Amitriptyline facilitated neuronal development and had protective effect on lidocaine-induced neurodegeneration, very likely through the activation of TrkA-signaling pathway in DRG.

42 CFR 476.94 - Notice of QIO initial denial determination and changes as a result of a DRG validation.

Code of Federal Regulations, 2012 CFR

2012-10-01

... changes as a result of a DRG validation. 476.94 Section 476.94 Public Health CENTERS FOR MEDICARE... changes as a result of a DRG validation. (a) Notice of initial denial determination—(1) Parties to be... retrospective review, (excluding DRG validation and post procedure review), within 3 working days of the initial...

42 CFR 476.94 - Notice of QIO initial denial determination and changes as a result of a DRG validation.

Code of Federal Regulations, 2013 CFR

2013-10-01

... changes as a result of a DRG validation. 476.94 Section 476.94 Public Health CENTERS FOR MEDICARE... changes as a result of a DRG validation. (a) Notice of initial denial determination—(1) Parties to be... working days of identification; (vi) For retrospective review, (excluding DRG validation and post...

42 CFR 476.96 - Review period and reopening of initial denial determinations and changes as a result of DRG...

Code of Federal Regulations, 2014 CFR

2014-10-01

... determinations and changes as a result of DRG validations. 476.96 Section 476.96 Public Health CENTERS FOR... and changes as a result of DRG validations. (a) General timeframe. A QIO or its subcontractor— (1... change as a result of a DRG validation. (b) Extended timeframes. (1) An initial denial determination or...

42 CFR 476.94 - Notice of QIO initial denial determination and changes as a result of a DRG validation.

Code of Federal Regulations, 2011 CFR

2011-10-01

... changes as a result of a DRG validation. 476.94 Section 476.94 Public Health CENTERS FOR MEDICARE... changes as a result of a DRG validation. (a) Notice of initial denial determination—(1) Parties to be... retrospective review, (excluding DRG validation and post procedure review), within 3 working days of the initial...

42 CFR 476.85 - Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations.

Code of Federal Regulations, 2013 CFR

2013-10-01

... determinations and changes as a result of DRG validations. 476.85 Section 476.85 Public Health CENTERS FOR... denial determinations and changes as a result of DRG validations. A QIO initial denial determination or change as a result of DRG validation is final and binding unless, in accordance with the procedures in...

42 CFR 476.85 - Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations.

Code of Federal Regulations, 2011 CFR

2011-10-01

... determinations and changes as a result of DRG validations. 476.85 Section 476.85 Public Health CENTERS FOR... denial determinations and changes as a result of DRG validations. A QIO initial denial determination or change as a result of DRG validation is final and binding unless, in accordance with the procedures in...

42 CFR 476.85 - Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations.

Code of Federal Regulations, 2012 CFR

2012-10-01

... determinations and changes as a result of DRG validations. 476.85 Section 476.85 Public Health CENTERS FOR... denial determinations and changes as a result of DRG validations. A QIO initial denial determination or change as a result of DRG validation is final and binding unless, in accordance with the procedures in...

Characterization of human dopamine responsive protein DRG-1 that binds to p75NTR-associated cell death executor NADE.

PubMed

Yu, Yao; Wang, Jiadong; Yuan, Hanying; Qin, Feng; Wang, Jing; Zhang, Nailing; Li, Yu-Yang; Liu, Jianping; Lu, Hong

2006-07-19

Expression of human dopamine responsive gene-1 (DRG-1) is up-regulated in response to treatment of dopamine in the rat astrocytes. However, its functions are not clear up to now. In the presented studies, DRG-1 was identified to be a conserved gene in the vertebrate and expressed abundantly in human testis, brain and skeletal muscle. DRG-1 was shown to interact with human p75NTR-associated cell death executor (NADE) in vivo and in vitro, and the interaction occurred in cytoplasm. The regions required for the interaction were subsequently mapped to the N-terminal of DRG-1 and the C-terminal of NADE. Furthermore, MTT assay showed that stable expression of DRG-1 in 293 cells could promote cell proliferation, and this promotion was suppressed by overexpression of NADE. In flow cytometry cell cycle analysis, overexpression of DRG-1 in 293 or PC12 cells increased the population of cells in the S phase with a concomitant decrease in G0/G1 population. These findings suggest that DRG-1 may contribute to the dopamine-induced cell growth, which is negatively regulated by NADE.

Is the timing of radiological intervention and treatment day associated with economic outcomes in DRG-financed health care systems: a case study.

PubMed

Napierala, Christoph; Boes, Stefan

2017-02-28

In 2012, Switzerland has introduced a diagnosis related group (DRG) system for hospital financing to increase the efficiency and transparency of hospital services and to reduce costs. However, little is known about the efficiency of specific processes within hospitals. The objective of this study is to describe the relationship between timing of radiological interventions, in particular scan and treatment day, and the length of stay (LOS) compliance in a hospital. This is a cross-sectional observational study based on administrative records of all DRG cases in a Swiss university hospital in 2013, enriched by data from the radiology information system and accounting details. The data are analysed using descriptive statistics and regression methods. Radiology and related treatment on a weekend is associated with a higher LOS compliance of approximately 22.12% (p<0.01) compared to scans and treatments on weekdays, controlling for gender, age and insurance of the patient, as well as detailed medical and radiology-related factors. The higher LOS compliance is driven by emergency cases, which supports the hypothesis that for those cases on weekends more efficient scan and treatment processes are in place. The study provides evidence on how days of radiological intervention are related to LOS compliance in a Swiss hospital under DRG and attempts to explain how this is linked to standardised operating procedures. Our results have implications regarding potential cost savings in hospital care through alignment of care processes, infrastructure planning and guidance of patient flows.

42 CFR 476.96 - Review period and reopening of initial denial determinations and changes as a result of DRG...

Code of Federal Regulations, 2013 CFR

2013-10-01

... determinations and changes as a result of DRG validations. 476.96 Section 476.96 Public Health CENTERS FOR... initial denial determinations and changes as a result of DRG validations. (a) General timeframe. A QIO or... initial denial determination or a change as a result of a DRG validation. (b) Extended timeframes. (1) An...

42 CFR 476.96 - Review period and reopening of initial denial determinations and changes as a result of DRG...

Code of Federal Regulations, 2012 CFR

2012-10-01

... determinations and changes as a result of DRG validations. 476.96 Section 476.96 Public Health CENTERS FOR... initial denial determinations and changes as a result of DRG validations. (a) General timeframe. A QIO or... initial denial determination or a change as a result of a DRG validation. (b) Extended timeframes. (1) An...

42 CFR 476.93 - Opportunity to discuss proposed initial denial determination and changes as a result of a DRG...

Code of Federal Regulations, 2011 CFR

2011-10-01

... determination and changes as a result of a DRG validation. 476.93 Section 476.93 Public Health CENTERS FOR... initial denial determination and changes as a result of a DRG validation. Before a QIO reaches an initial denial determination or makes a change as a result of a DRG validation, it must— (a) Promptly notify the...

42 CFR 476.93 - Opportunity to discuss proposed initial denial determination and changes as a result of a DRG...

Code of Federal Regulations, 2013 CFR

2013-10-01

... determination and changes as a result of a DRG validation. 476.93 Section 476.93 Public Health CENTERS FOR... initial denial determination and changes as a result of a DRG validation. Before a QIO reaches an initial denial determination or makes a change as a result of a DRG validation, it must— (a) Promptly notify the...

42 CFR 476.85 - Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations.

Code of Federal Regulations, 2014 CFR

2014-10-01

... determinations and changes as a result of DRG validations. 476.85 Section 476.85 Public Health CENTERS FOR... changes as a result of DRG validations. A QIO initial denial determination or change as a result of DRG validation is final and binding unless, in accordance with the procedures in part 473— (a) The initial denial...

42 CFR 476.93 - Opportunity to discuss proposed initial denial determination and changes as a result of a DRG...

Code of Federal Regulations, 2012 CFR

2012-10-01

... determination and changes as a result of a DRG validation. 476.93 Section 476.93 Public Health CENTERS FOR... initial denial determination and changes as a result of a DRG validation. Before a QIO reaches an initial denial determination or makes a change as a result of a DRG validation, it must— (a) Promptly notify the...

42 CFR 476.93 - Opportunity to discuss proposed initial denial determination and changes as a result of a DRG...

Code of Federal Regulations, 2014 CFR

2014-10-01

... determination and changes as a result of a DRG validation. 476.93 Section 476.93 Public Health CENTERS FOR... and changes as a result of a DRG validation. Before a QIO reaches an initial denial determination or makes a change as a result of a DRG validation, it must— (a) Promptly notify the provider or supplier...

42 CFR 476.96 - Review period and reopening of initial denial determinations and changes as a result of DRG...

Code of Federal Regulations, 2011 CFR

2011-10-01

... determinations and changes as a result of DRG validations. 476.96 Section 476.96 Public Health CENTERS FOR... initial denial determinations and changes as a result of DRG validations. (a) General timeframe. A QIO or... initial denial determination or a change as a result of a DRG validation. (b) Extended timeframes. (1) An...

The dam replacing gene product enhances Neisseria gonorrhoeae FA1090 viability and biofilm formation

PubMed Central

Kwiatek, Agnieszka; Bacal, Pawel; Wasiluk, Adrian; Trybunko, Anastasiya; Adamczyk-Poplawska, Monika

2014-01-01

Many Neisseriaceae do not exhibit Dam methyltransferase activity and, instead of the dam gene, possess drg (dam replacing gene) inserted in the leuS/dam locus. The drg locus in Neisseria gonorrhoeae FA1090 has a lower GC-pairs content (40.5%) compared to the whole genome of N. gonorrhoeae FA1090 (52%). The gonococcal drg gene encodes a DNA endonuclease Drg, with GmeATC specificity. Disruption of drg or insertion of the dam gene in gonococcal genome changes the level of expression of genes as shown by transcriptome analysis. For the drg-deficient N. gonorrhoeae mutant, a total of 195 (8.94% of the total gene pool) genes exhibited an altered expression compared to the wt strain by at least 1.5 fold. In dam-expressing N. gonorrhoeae mutant, the expression of 240 genes (11% of total genes) was deregulated. Most of these deregulated genes were involved in translation, DNA repair, membrane biogenesis and energy production as shown by cluster of orthologous group analysis. In vivo, the inactivation of drg gene causes the decrease of the number of live neisserial cells and long lag phase of growth. The insertion of dam gene instead of drg locus restores cell viability. We have also shown that presence of the drg gene product is important for N. gonorrhoeae FA1090 in adhesion, including human epithelial cells, and biofilm formation. Biofilm produced by drg-deficient strain is formed by more dispersed cells, compared to this one formed by parental strain as shown by scanning electron and confocal microscopy. Also adherence assays show a significantly smaller biomass of formed biofilm (OD570 = 0.242 ± 0.038) for drg-deficient strain, compared to wild-type strain (OD570 = 0.378 ± 0.057). Dam-expressing gonococcal cells produce slightly weaker biofilm with cells embedded in an extracellular matrix. This strain has also a five times reduced ability for adhesion to human epithelial cells. In this context, the presence of Drg is more advantageous for N. gonorrhoeae biology than Dam presence. PMID:25566225

A Study to Determine Military Office Manpower at WRAMC (Walter-Reed Army Medical Center) that is Diverted from Patient Care

DTIC Science & Technology

1986-01-01

related groups (DRG) with weighted "pass throughs" (i.e., training, research, consulting, etc.), these studies may enable Health 3 Services Command to...proposed military equivalent to diagnostic related groups (DRG). 45 FOOTNOTES 1U.S. Department of the Army, Health Care Studies and Clinical Investigation...performed by patient care providers within the military health care system is limited to activities that are directly related to patient care.1 The

Design, development and first validation of a transcoding system from ICD-9-CM to ICD-10 in the IT.DRG Italian project.

PubMed

Della Mea, Vincenzo; Vuattolo, Omar; Frattura, Lucilla; Munari, Flavia; Verdini, Eleonora; Zanier, Loris; Arcangeli, Laura; Carle, Flavia

2015-01-01

In Italy, ICD-9-CM is currently used for coding health conditions at hospital discharge, but ICD-10 is being introduced thanks to the IT-DRG Project. In this project, one needed component is a set of transcoding rules and associated tools for easing coders work in the transition. The present paper illustrates design and development of those transcoding rules, and their preliminary testing on a subset of Italian hospital discharge data.

Targeting the Neural Microenvironment in Prostate Cancer

DTIC Science & Technology

2015-10-01

nerve-prostate cancer cell interactions. Subtask 1: Sub-aim 2.1. DRG PNI studies with DU145 prostate cancer cells (months 4-15) We have received...Subtask 2: Sub-aim 2.2. DRG PNI studies with other prostate cancer cell lines (months 12- 36) This will be carried beginning in Year 2 Subtask 3: Sub...potentiated by GFRA1. These studies suggest that GFRA1 may be partially limiting in our system . Moving forward we will need explore whether GFRA1

Diosgenin-3-O-alpha-L-rhamnopyranosyl-(1 --> 4)-beta-D-glucopyranoside obtained as a new anticancer agent from Dioscorea futschauensis induces apoptosis on human colon carcinoma HCT-15 cells via mitochondria-controlled apoptotic pathway.

PubMed

Wang, San-Long; Cai, Bing; Cui, Cheng-Bin; Liu, Hong-Wei; Wu, Chun-Fu; Yao, Xin-Sheng

2004-06-01

Diosgenin-3-O-alpha-L-rhamnopyranosyl-(1 --> 4)-beta-D-glucopyranoside (DRG) is a well-known pentacyclic triterpene glycoside newly isolated from the rhizomes of Dioscorea futschauensis R. Kunth (Dioscoreaceae) by our group. In the present work, the inhibitory effect of DRG on the cell proliferation of human cancer cell lines was examined to reveal for the first time that DRG shows stronger anticancer activity than that of the positive control cisplatin. DRG inhibited the proliferation of human cancer cells, A431, A2780, A549, K562, and HCT-15, with IC50 (micromol L(-1)) values of 9.33 +/- 0.22, 18.7 +/- 0.16, 9.98 +/- 0.38, 6.44 +/- 0.10, and 5.86 +/- 0.14 respectively. It was then found, by morphological observation, "DNA ladder" detection and flow cytometric analysis, that DRG exerts its anticancer effect through inducing apoptosis on HCT-15 cells. Furthermore, it has been demonstrated that DRG triggers a mitochondria-controlled apoptotic pathway to induce apoptosis on HCT-15 cells, which involves the reduction of the mitochondrial potential (deltapsim), the release of cytochrome c from mitochondria into the cytosol, and the down-regulation of the ratio of Bcl-2/Bax expression level. The present results reasonably suggest that regulating the balance of Bcl-2/Bax expression level plays a key role in the DRG-induced apoptosis. Such findings provide novel knowledge to elucidate the biological properties of DRG, even though DRG was discovered early in the late 1960s. These results suggest that DRG may be a good candidate as a chemotherapeutic agent to treat human colon carcinoma.

The different roles of opioid receptors in the inhibitory effects induced by sacral dorsal root ganglion stimulation on nociceptive and nonnociceptive conditions in cats.

PubMed

Wang, Zhaoxia; Liao, Limin; Deng, Han; Li, Xing; Chen, Guoqing; Liao, Xiwen

2018-06-04

To examine the roles of opioid receptors in the inhibition of nociceptive and nonnociceptive bladder reflexes by sacral dorsal root ganglion (DRG) stimulation in cats. Hook electrodes were placed in the right S1 and S2 DRG of cats. The bladders were infused with physiologic saline or 0.25% acetic acid (AA). Naloxone (0.1, 0.3, and 1 mg/kg), an opioid receptor antagonist, was administered intravenously. S1 or S2 DRG stimulation was applied before and after administering the drug. Multiple cystometrograms were performed to determine the effects of DRG stimulation and opioid receptors on the micturition reflex under nociceptive and non-nociceptive conditions. AA significantly (P < 0.01) reduced bladder capacity (BC). DRG stimulation at threshold (T) and 1.5 T significantly increased BC of the saline control under nociceptive and non-nociceptive conditions. When saline was infused, naloxone (0.1-1 mg/kg) significantly (P < 0.01) reduced BC; however, naloxone did not change BC during AA irritation. During saline infusion, naloxone (0.3 and 1 mg/kg) partly blocked S1 DRG stimulation-induced inhibition but had only a slight effect on S2 DRG stimulation. During AA infusion, naloxone (0.3 and 1 mg/kg) only partially blocked S1 DRG stimulation at T intensity but not during 1.5 T stimulation. However, no doses of naloxone significantly affected S2 DRG stimulation. Opioid receptors play a role in sacral DRG stimulation on non-nociceptive condition but are not involved in the inhibitory effect of stimulation in nociceptive conditions. © 2018 Wiley Periodicals, Inc.

Nursing diagnoses, diagnosis-related group, and hospital outcomes.

PubMed

Welton, John M; Halloran, Edward J

2005-12-01

There are no nursing centric data in the hospital discharge abstract. This study investigates whether adding nursing data in the form of nursing diagnoses to medical diagnostic data in the discharge abstract can improve overall explanation of variance in commonly studied hospital outcomes. A retrospective analyses of 123,241 sequential patient admissions to a university hospital in a Midwestern city was performed. Two data sets were combined: (1) a daily collection of patient assessments by nurses using nursing diagnosis terminology (NDX); and (2) the summary discharge information from the hospital discharge abstract including diagnosis-related group (DRG) and all payer refined DRG (APR-DRG). Each of 61 daily NDX observations were collapsed as frequency of occurrence for the hospital stay and inserted into the discharge abstract. NDX was then compared to both DRG and APR-DRG across 5 hospital outcome variables using multivariate regression or logistic regression. In all statistical models, DRG, APR-DRG, and NDX were significantly associated with the 5 hospital outcome variables (P <.0001). When NDX was added to models containing either the DRG or the APR-DRG, explanatory power (R2) and model discrimination (c statistic) improved by 30% to 146% across the outcome variables of hospital length of stay, ICU length of stay, total charges, probably of death, and discharge to a nursing home (P <.0001). The findings support the contention that nursing care is an independent predictor of patient hospital outcomes. These nursing data are not redundant with the medical diagnosis, in particular, the DRG. The findings support the argument for including nursing care data in the hospital discharge abstract. Further study is needed to clarify which nursing data are the best fit for the current hospital discharge abstract data collection scheme.

[Partial dorsal root rhizotomy increases the anterograde transportation of neunotrophic factors in primary sensory neuron].

PubMed

Long, Shuang-lian; Li, Yong-mei; Yuan, Yuan; Wang, Ting-hua; Wu, Lin-yan

2005-05-01

To investigate whether partial dorsal root rhizotomy promotes the anterograde Five adult cats were transportation of BDNF, NT-3 and GDNF in the primary sensory neuron. Subjected to unilateral spared root rhizotomy (the DRGs of L1-L5 and L7-S2 were removed, but L6 DRG was spared) and bilateral dorsal roots of L6 were ligated at the same time. Three days after operation, dorsal roots were taken out and made into frozen sections 20 microm in thickness. The sections were stained using specific BDNF, NT-3, GDNF antibody (1:1500) by ABC method. The immunoreactive density was observed in a site near DRG and a site near spinal cord. In the control group (with spared L6 DRG), there were no marked differences in NT-3 and GDNF immunoreactivity between the site near DRG and the site near spinal cord, while BDNF immunoreactivity was more intense in the site near DRG than that in the site near spinal cord. In the operation group, the immunoreactivity of each neurotrophin in the site near DRG was stronger than that in the site near spinal cord, and the immunoreactivities of BDNF, NT-3, GDNF in the site near DRG of the operation were stronger than those of the control group respectively. The increasing of immunoreactivities of neurotrophins near DRG following partial dorsal root rhizotomy suggests that partial dorsal root rhizotomy can promote their anterograde transportation from spared DRG to the spinal cord.

[Medical records, DRG and intensive care patients].

PubMed

Aardal, Sidsel; Berge, Kjersti; Breivik, Kjell; Flaatten, Hans K

2005-04-07

In order to control the quality of the medical report after a hospital stay with regards to the stay in the intensive care unit (ICU), and to cheque for correct DRG grouping, this study of 428 patients treated in our ICU in 2003 was conducted. All ICU patients from 2003 were found in our database, which includes specific ICD-10 diagnosis and specific ICU procedures. The medical record summarising the hospital stay (epicrisis) was retrieved for each patient from the hospital's electronic patient files and controlled for correct information regarding the ICU stay. DRG groups for each patient were retrieved from the hospital's administrative database. All stays were re-coded, with all information about the ICU stay was also included. The new DRG codes were compared with the old ones, and the difference in DRG points computed. The description of the stay in the ICU was missing or very insufficient in 46% of the records. In the DRG control we found that an additional 347.37 DRG points (18.4% of the original sum of all DRG points) were missing, corresponding to a loss to the hospital of 6.2 million NOK. In addition we discovered missing codes for tracheostomy corresponding to 2.8 million NOK, giving a total loss of 9 million NOK. This study confirms that an adequate description of the stay in the ICU is insufficient in a large number of medical records. This also leads to incorrect DRG grouping of many patients and significant financial losses to the hospital.

Study of the damage rate caused by intervertebral foramen type inside and outside and the pass of the intervertebral DRG RF puncture way.

PubMed

Sun, Jiashu; Zhang, Haitao

2014-09-01

This paper was to analyze and contrast the damage rate on the thoracic segment different position of the dorsal root ganglion(dorsal root ganglion, DRG) caused by different puncture path in radiofrequency ablation, thus the best RF target way for the thoracic segment of different types of DRG was confirmed. According to the difference of puncture and ablation damage way, 14 segmental spinal specimens were randomly divided into three groups, and then conducted DRG radiofrequency damage on percutaneous puncture path according to the type of DRG position.The damage effect of different puncture path by the judgment standard of the result of pathology analyzed. The experiment showed that RF damage of group A were 72.58 ± 18.88%, 54.16 ± 24.84% and 32.85 ± 28.11%; that of group B were 771.86 ± 15.15% and 72.02 ± 17.86%, 57.14 ± 18.02% and 52.47 ± 20.64%, 68.75 ± 14.63% and 71.78 ± 16.00%; and that of group C were 82.46 ± 14.10%, 81.53 ± 11.81% and 80.83 ± 13.33%. It was concluded that the singleness of DRG puncture route is one of the important reasons for the poor thoracic segments DRG radiofrequency (RF) ablation effect. While according to the type of DRG different positions with double joint puncture path can significantly improve the rate of DRG RF damage.

Amitriptyline Activates TrkA to Aid Neuronal Growth and Attenuate Anesthesia-Induced Neurodegeneration in Rat Dorsal Root Ganglion Neurons

PubMed Central

Zheng, Xiaochun; Chen, Feng; Zheng, Ting; Huang, Fengyi; Chen, Jianghu; Tu, Wenshao

2016-01-01

Abstract Tricyclic antidepressant amitriptyline (AM) has been shown to exert neurotrophic activity on neurons. We thus explored whether AM may aid the neuronal development and protect anesthesia-induced neuro-injury in young spinal cord dorsal root ganglion (DRG) neurons. The DRG explants were prepared from 1-day-old rats. The effect of AM on aiding DRG neural development was examined by immunohistochemistry at dose-dependent manner. AM-induced changes in gene and protein expressions, and also phosphorylation states of tyrosine kinases receptor A (TrkA) and B (TrkB) in DRG, were examined by quantitative real-time polymerase chain reaction and western blot. The effect of AM on attenuating lidocaine-induced DRG neurodegeneration was examined by immunohistochemistry, and small interfering RNA (siRNA)-mediated TrkA/B down-regulation. Amitriptyline stimulated DRG neuronal development in dose-dependent manner, but exerted toxic effect at concentrations higher than 10 M. AM activated TrkA in DRG through phosphorylation, whereas it had little effect on TrkB-signaling pathway. AM reduced lidocaine-induced DRG neurodegeneration by regenerating neurites and growth cones. Moreover, the neuroprotection of AM on lidocaine-injured neurodegeneration was blocked by siRNA-mediated TrkA down-regulation, but not by TrkB down-regulation. Amitriptyline facilitated neuronal development and had protective effect on lidocaine-induced neurodegeneration, very likely through the activation of TrkA-signaling pathway in DRG. PMID:27149473

Effect of artemisinin on neuropathic pain mediated by P2X4 receptor in dorsal root ganglia.

PubMed

Ying, Mofeng; Liu, Hui; Zhang, Tengling; Jiang, Chenxu; Gong, Yingxin; Wu, Bing; Zou, Lifang; Yi, Zhihua; Rao, Shenqiang; Li, Guilin; Zhang, Chunping; Jia, Tianyu; Zhao, Shanhong; Yuan, Huilong; Shi, Liran; Li, Lin; Liang, Shangdong; Liu, Shuangmei

2017-09-01

Neuropathic pain is a type of chronic pain caused by nervous system damage and dysfunction. The pathogenesis of chronic pain is complicated, and there are no effective therapies for neuropathic pain. Studies show that the P2X 4 receptor expressed in the satellite glial cells (SGCs) of dorsal root ganglia (DRG) is related to neuropathic pain. Artemisinin is a monomeric component extracted from traditional Chinese medicine and has a variety of important pharmacological effects and potential applications. This study observed the effect of artemisinin on neuropathic pain and delineated its possible mechanism. The chronic constriction injury (CCI) rat model was used in this study. The results demonstrated that artemisinin relieved pain behaviors in the CCI rats, inhibited the expression of P2X 4 receptor in the DRG, and decreased the ATP-activated currents in HEK293 cells transfected with P2X 4 plasmid. Dual-labeling immunofluorescence showed that the coexpression of P2X 4 receptor and glial fibrillary acidic protein (GFAP) in the DRG of CCI rats was increased compared to control rats. After CCI rats were treated with artemisinin, the coexpression of P2X 4 receptor and GFAP in the DRG was significantly decreased compared to the CCI group. This finding suggested that artemisinin could inhibit the nociceptive transmission mediated by P2X 4 receptor in the DRG SGCs and thus relieve pain behaviors in the CCI rats. Copyright © 2017 Elsevier Ltd. All rights reserved.

Inflammation and nerve injury induce expression of pancreatitis-associated protein-II in primary sensory neurons.

PubMed

He, Shao-Qiu; Yao, Jun-Ru; Zhang, Fang-Xiong; Wang, Qiong; Bao, Lan; Zhang, Xu

2010-04-26

Pancreatitis-associated protein (PAP)-I and -II, lectin-related secretory proteins, are members of the regenerating gene (Reg) family. Although expression of PAP-I was found in the dorsal root ganglion (DRG) neurons following peripheral nerve injury and cystitis, whether PAP-II could be expressed in DRG neurons in chronic pain models remains unclear. The present study shows an inflammation- and nerve injury-triggered expression of PAP-II in rat DRG neurons. In situ hybridization showed that only a few DRG neurons normally contained PAP-I and -II mRNAs. After peripheral inflammation, PAP-I and -II mRNAs were present in over half of small DRG neurons. Such an elevated expression of PAP-I and -II reached the peak level on the second day. Immunostaining showed that the expression of PAP-II was mostly increased in the isolectin B4-positive subset of small DRG neurons after inflammation. Furthermore, the expression of PAP-II was also induced in DRG neurons after peripheral nerve injury. Interestingly, PAP-II expression was shifted from small neurons on day 2 to large DRG neurons that expressed neuropeptide Y during the later post-injury days. These results suggest that PAP-II may play potential roles in the modulation of spinal sensory pathways in pathological pain states.

[Comparison of pedicle and free tissue transfers in the German DRG system].

PubMed

Lotter, O; Stahl, S; Hohenstein, C; Schaller, H-E; Jaminet, P

2011-12-01

Diagnosis-Related Groups (DRGs) are a patient classification system grouping related types of patients to the resources they have consumed. In this analysis, we compared pedicle and free flaps in plastic and reconstructive surgery in the actual German DRG system. After grouping common flaps while systematically modifying the diagnosis, the operative procedure(s), and the receptor site, reimbursement and thresholds of length of stay were identified. The mean value of the average length of stay was higher in free flaps as compared to pedicle flaps (15 vs. 9 days) and the mean reimbursement in free flaps was almost twice as high as in pedicle flaps (8 936 € vs. 4 582 €). Regarding the diagnosis, third-grade open fractures in pedicle flaps and full-thickness burns in free flaps are in the vanguard of reimbursement. Higher DRG conformity is generally found with free flaps. Different possibilities in coding the procedures and the strong dependence on the underlying diagnosis lead to variations of remuneration and length of stay, which are not explainable and sometimes even seem paradoxical. Furthermore, mixed calculation creates DRGs that lose the ability to describe the real effort. © Georg Thieme Verlag KG Stuttgart · New York.

Factors affecting profitability for craniotomy.

PubMed

Popp, A John; Scrime, Todd; Cohen, Benjamin R; Feustel, Paul J; Petronis, Karen; Habiniak, Sharon; Waldman, John B; Vosburgh, Margaret M

2002-04-15

The authors studied factors influencing hospital profitability after craniotomy in patients who underwent craniotomy coded as diagnosis-related group (DRG) 1 (17 years of age with nontraumatic disease without complication) and who met their hospital's craniotomy pathway criteria and had a hospital length of stay 4 days or less during a 20-month period. Data in all patients meeting these criteria (76 cases) were collected and collated from various hospital databases. Twenty-one cases were profitable and 55 were not. Variables traditionally influencing cost of care, such as surgeon, procedure, length of operation, and pharmacy use had no significant effect on whether a patient was profitable. The most important influence on profitability was the individual payor. Cases in which care was reimbursed under the prospective payment system based on DRGs were nearly always profitable whereas those covered by per diem plans were nearly always nonprofitable. 1) Hospital information systems should be customized to deliver consolidated data for timely analysis of cost of care for individual patients. This information may be useful in negotiating profitable contracts. 2) A clinical pathway was successful in reducing the difference in cost of care between profitable and nonprofitable postcraniotomy cases. 3) In today's health care environment both cost containment and revenue assume importance in determining profitability.

[Main results of the Swiss study on DRGs (Casemix Study)].

PubMed

Casemix, E

1989-01-01

Sponsored by the Health Administrations of nine cantons, this study was conducted by the University Institute of Social and Preventive Medicine in Lausanne in order to assess how DRGs could be used within the Swiss context. A data base mainly provided by the Swiss VESKA statistics was used. The first step provided the transformation of Swiss diagnostic and intervention codes into US codes, allowing direct use of the Yale Grouper for DRG. The second step showed that the overall performance of DRG in terms of variability reduction of the length of stay was similar to the one observed in US; there are, however, problems when the homogeneity of medicotechnical procedures for DRG is considered. The third steps showed how DRG could be used as an account unit in hospital, and how costs per DRG could be estimated. Other examples of applications of DRG were examined, for example comparison of Casemix or length of stay between hospitals.

Pressure wave injuries to rat dorsal root ganglion cells in culture caused by high-energy missiles.

PubMed

Suneson, A; Hansson, H A; Lycke, E; Seeman, T

1989-01-01

A high-energy missile impact in an extremity of an animal creates a shock wave which is rapidly dispersed as a burst of oscillating pressure waves that traverses the entire body causing local, regional, and distant injuries. The present study was performed on dorsal root ganglion (DRG) cells, cultured for 3 weeks, to elucidate the cellular mechanism for damage of nerve cells, using a simplified test system. A model system was developed allowing exposure of DRG cultures to a burst of high-frequency oscillating pressure waves, comparable to those recorded in animals after high-energy missile extremity impact. The pressure waves were induced by impact of a high-energy missile in a rubber tube filled with water, in which nerve cell cultures were kept in a closed rubber glove filled with tissue culture medium. The pressure waves had a duration of 0.5-1.5 ms and a frequency spectrum ranging from 0-250 kHz. Within minutes the neurites showed changes in their microtubules. In addition, varicosities, enriched with tubulin immunoreactive material, became irregularly studded along the nerve cell processes. Scattered DRG cells were initially permeable to the marker complex Evans-blue albumin (EBA), used as an indicator of the ability of the plasma membranes to exclude proteins. After 6 hr, however, almost every DRG neuron was intensely stained by EBA. Concomitantly, there was swelling of the nerve cell cytoplasm and organelles, and, to a variable extent, neurofilament tangles were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Blockade of persistent sodium currents contributes to the riluzole-induced inhibition of spontaneous activity and oscillations in injured DRG neurons.

PubMed

Xie, Rou-Gang; Zheng, Da-Wei; Xing, Jun-Ling; Zhang, Xu-Jie; Song, Ying; Xie, Ya-Bin; Kuang, Fang; Dong, Hui; You, Si-Wei; Xu, Hui; Hu, San-Jue

2011-04-25

In addition to a fast activating and immediately inactivating inward sodium current, many types of excitable cells possess a noninactivating or slowly inactivating component: the persistent sodium current (I(NaP)). The I(NaP) is found in normal primary sensory neurons where it is mediated by tetrodotoxin-sensitive sodium channels. The dorsal root ganglion (DRG) is the gateway for ectopic impulses that originate in pathological pain signals from the periphery. However, the role of I(NaP) in DRG neurons remains unclear, particularly in neuropathic pain states. Using in vivo recordings from single medium- and large-diameter fibers isolated from the compressed DRG in Sprague-Dawley rats, we show that local application of riluzole, which blocks the I(NaP), also inhibits the spontaneous activity of A-type DRG neurons in a dose-dependent manner. Significantly, riluzole also abolished subthreshold membrane potential oscillations (SMPOs), although DRG neurons still responded to intracellular current injection with a single full-sized spike. In addition, the I(NaP) was enhanced in medium- and large-sized neurons of the compressed DRG, while bath-applied riluzole significantly inhibited the I(NaP) without affecting the transient sodium current (I(NaT)). Taken together, these results demonstrate for the first time that the I(NaP) blocker riluzole selectively inhibits I(NaP) and thereby blocks SMPOs and the ectopic spontaneous activity of injured A-type DRG neurons. This suggests that the I(NaP) of DRG neurons is a potential target for treating neuropathic pain at the peripheral level.

Casemix in the Islamic Republic of Iran: current knowledge and attitudes of health care staff.

PubMed

Ghaffari, S; Doran, C M; Wilson, A

2008-01-01

Casemix is a tool that classifies patients according to their clinical similarity and the homogeneity of resources required. A descriptive study was conducted to assess the level of knowledge and attitude toward the casemix-based funding system among staff working in the Iranian Social Security Organization in Tehran. The survey showed that knowledge of casemix and diagnosis-related groups (DRG) was poor among the study group and any attempt to implement the casemix system--which about three-quarters of high-level staff had never heard of--would be likely to fail. This highlights the necessity for creating awareness of the casemix and DRG systems among the hospital staff before any action takes place.

Voltage-gated sodium channel expression in mouse DRG after SNI leads to re-evaluation of projections of injured fibers.

PubMed

Laedermann, Cédric J; Pertin, Marie; Suter, Marc R; Decosterd, Isabelle

2014-03-11

Dysregulation of voltage-gated sodium channels (Na(v)s) is believed to play a major role in nerve fiber hyperexcitability associated with neuropathic pain. A complete transcriptional characterization of the different isoforms of Na(v)s under normal and pathological conditions had never been performed on mice, despite their widespread use in pain research. Na(v)s mRNA levels in mouse dorsal root ganglia (DRG) were studied in the spared nerve injury (SNI) and spinal nerve ligation (SNL) models of neuropathic pain. In the SNI model, injured and non-injured neurons were intermingled in lumbar DRG, which were pooled to increase the tissue available for experiments. A strong downregulation was observed for every Na(v)s isoform expressed except for Na(v)1.2; even Na(v)1.3, known to be upregulated in rat neuropathic pain models, was lower in the SNI mouse model. This suggests differences between these two species. In the SNL model, where the cell bodies of injured and non-injured fibers are anatomically separated between different DRG, most Na(v)s were observed to be downregulated in the L5 DRG receiving axotomized fibers. Transcription was then investigated independently in the L3, L4 and L5 DRG in the SNI model, and an important downregulation of many Na(v)s isoforms was observed in the L3 DRG, suggesting the presence of numerous injured neurons there after SNI. Consequently, the proportion of axotomized neurons in the L3, L4 and L5 DRG after SNI was characterized by studying the expression of activating transcription factor 3 (ATF3). Using this marker of nerve injury confirmed that most injured fibers find their cell bodies in the L3 and L4 DRG after SNI in C57BL/6 J mice; this contrasts with their L4 and L5 DRG localization in rats. The spared sural nerve, through which pain hypersensitivity is measured in behavioral studies, mostly projects into the L4 and L5 DRG. The complex regulation of Na(v)s, together with the anatomical rostral shift of the DRG harboring injured fibers in C57BL/6 J mice, emphasize that caution is necessary and preliminary anatomical experiments should be carried out for gene and protein expression studies after SNI in mouse strains.

Voltage-gated sodium channel expression in mouse DRG after SNI leads to re-evaluation of projections of injured fibers

PubMed Central

2014-01-01

Background Dysregulation of voltage-gated sodium channels (Navs) is believed to play a major role in nerve fiber hyperexcitability associated with neuropathic pain. A complete transcriptional characterization of the different isoforms of Navs under normal and pathological conditions had never been performed on mice, despite their widespread use in pain research. Navs mRNA levels in mouse dorsal root ganglia (DRG) were studied in the spared nerve injury (SNI) and spinal nerve ligation (SNL) models of neuropathic pain. In the SNI model, injured and non-injured neurons were intermingled in lumbar DRG, which were pooled to increase the tissue available for experiments. Results A strong downregulation was observed for every Navs isoform expressed except for Nav1.2; even Nav1.3, known to be upregulated in rat neuropathic pain models, was lower in the SNI mouse model. This suggests differences between these two species. In the SNL model, where the cell bodies of injured and non-injured fibers are anatomically separated between different DRG, most Navs were observed to be downregulated in the L5 DRG receiving axotomized fibers. Transcription was then investigated independently in the L3, L4 and L5 DRG in the SNI model, and an important downregulation of many Navs isoforms was observed in the L3 DRG, suggesting the presence of numerous injured neurons there after SNI. Consequently, the proportion of axotomized neurons in the L3, L4 and L5 DRG after SNI was characterized by studying the expression of activating transcription factor 3 (ATF3). Using this marker of nerve injury confirmed that most injured fibers find their cell bodies in the L3 and L4 DRG after SNI in C57BL/6 J mice; this contrasts with their L4 and L5 DRG localization in rats. The spared sural nerve, through which pain hypersensitivity is measured in behavioral studies, mostly projects into the L4 and L5 DRG. Conclusions The complex regulation of Navs, together with the anatomical rostral shift of the DRG harboring injured fibers in C57BL/6 J mice, emphasize that caution is necessary and preliminary anatomical experiments should be carried out for gene and protein expression studies after SNI in mouse strains. PMID:24618114

[Can Topical Negative Pressure Therapy be Performed as a Cost-Effective General Surgery Procedure in the German DRG System?].

PubMed

Hirche, Z; Xiong, L; Hirche, C; Willis, S

2016-04-01

Topical negative pressure therapy (TNPT) has been established for surgical wound therapy with different indications. Nevertheless, there is only sparse evidence regarding its therapeutic superiority or cost-effectiveness in the German DRG system (G-DRG). This study was designed to analyse the cost-effectiveness of TNPT in the G-DRG system with a focus on daily treatment costs and reimbursement in a general surgery care setting. In this retrospective study, we included 176 patients, who underwent TNPT between 2007 and 2011 for general surgery indications. Analysis of the cost-effectiveness involved 149 patients who underwent a simulation to calculate the reimbursement with or without TNPT by a virtual control group in which the TNP procedure was withdrawn for DRG calculation. This was followed by a calculation of costs for wound dressings and TNPT rent and material costs. Comparison between the "true" and the virtual group enabled calculation of the effective remaining surplus per case. Total reimbursement by included TNPT cases was 2,323 ,70.04 €. Costs for wound dressings and TNPT rent were 102,669.20 €. In 41 cases there was a cost-effectiveness (27.5%) with 607,422.03 € with TNP treatment, while the control group without TNP generated revenues of 442,015.10 €. Costs for wound dressings and TNPT rent were 47,376.68 €. In the final account we could generate a cost-effectiveness of 6759 € in 5 years per 149 patients by TNPT. In 108 cases there was no cost-effectiveness (72.5%). TNPT applied in a representative general surgery setting allows for wound therapy without a major financial burden. Based on the costs for wound dressings and TNPT rent, a primarily medically based decision when to use TNPT can be performed in a balanced product cost accounting. This study does not analyse the superiority of TNPT in wound care, so further prospective studies are required which focus on therapeutic superiority and cost-effectiveness. Georg Thieme Verlag KG Stuttgart · New York.

Reduction of voltage gated sodium channel protein in DRG by vector mediated miRNA reduces pain in rats with painful diabetic neuropathy.

PubMed

Chattopadhyay, Munmun; Zhou, Zhigang; Hao, Shuanglin; Mata, Marina; Fink, David J

2012-03-22

Painful neuropathy is a common complication of diabetes. Previous studies have identified significant increases in the amount of voltage gated sodium channel isoforms Na(V)1.7 and Na(V)1.3 protein in the dorsal root ganglia (DRG) of rats with streptozotocin (STZ)-induced diabetes. We found that gene transfer-mediated release of the inhibitory neurotransmitters enkephalin or gamma amino butyric acid (GABA) from DRG neurons in diabetic animals reduced pain-related behaviors coincident with a reduction in Na(V)1.7 protein levels in DRG in vivo. To further evaluate the role of Na(V)α subunit levels in DRG in the pathogenesis of pain in diabetic neuropathy, we constructed a non-replicating herpes simplex virus (HSV)-based vector expressing a microRNA (miRNA) against Na(V)α subunits. Subcutaneous inoculation of the miRNA-expressing HSV vector into the feet of diabetic rats to transduce DRG resulted in a reduction in Na(V)α subunit levels in DRG neurons, coincident with a reduction in cold allodynia, thermal hyperalgesia and mechanical hyperalgesia. These data support the role of increased Na(V)α protein in DRG in the pathogenesis of pain in diabetic neuropathy, and provide a proof-of-principle demonstration for the development of a novel therapy that could be used to treat intractable pain in patients with diabetic neuropathy.

Identification of DRG-1 As a Melanoma-Associated Antigen Recognized by CD4+ Th1 Cells

PubMed Central

Kiniwa, Yukiko; Li, Jiang; Wang, Mingjun; Sun, Chuang; Lee, Jeffrey E.; Wang, Rong-Fu; Wang, Helen Y.

2015-01-01

Immunotherapy has emerged as a promising strategy for the treatment of metastatic melanoma. Clinical studies have demonstrated the feasibility of cancer immunotherapy using tumor antigens recognized by CD8+ T cells. However, the overall immune responses induced by these antigens are too weak and transient to induce tumor regression in the majority of patients who received immunization. A growing body of evidence suggests that CD4+ T helper (Th) cells play an important role in antitumor immunity. Therefore, the identification of MHC class II-restricted tumor antigens capable of stimulating CD4+ T cells may provide opportunities for developing effective cancer vaccines. To this end, we describe the identification of developmentally regulated GTP-binding protein 1 (DRG-1) as a melanoma-associated antigen recognized by HLA-DR11-restricted CD4+ Th1 cells. Epitope mapping analysis showed that the DRG1248-268 epitope of DRG-1 was required for T cell recognition. Reverse transcription-polymerase chain reaction revealed that DRG-1 was highly expressed in melanoma cell lines but not in normal tissues. DRG-1 knockdown by lentiviral-based shRNA suppressed melanoma cell proliferation and soft agar colony formation. Taken together, these data suggest that DRG-1 plays an important role in melanoma cell growth and transformation, indicating that DRG1 may represent a novel target for CD4+ T cell-mediated immunotherapy in melanoma. PMID:25993655

Identification of DRG-1 As a Melanoma-Associated Antigen Recognized by CD4+ Th1 Cells.

PubMed

Kiniwa, Yukiko; Li, Jiang; Wang, Mingjun; Sun, Chuang; Lee, Jeffrey E; Wang, Rong-Fu; Wang, Helen Y

2015-01-01

Immunotherapy has emerged as a promising strategy for the treatment of metastatic melanoma. Clinical studies have demonstrated the feasibility of cancer immunotherapy using tumor antigens recognized by CD8(+) T cells. However, the overall immune responses induced by these antigens are too weak and transient to induce tumor regression in the majority of patients who received immunization. A growing body of evidence suggests that CD4(+) T helper (Th) cells play an important role in antitumor immunity. Therefore, the identification of MHC class II-restricted tumor antigens capable of stimulating CD4(+) T cells may provide opportunities for developing effective cancer vaccines. To this end, we describe the identification of developmentally regulated GTP-binding protein 1 (DRG-1) as a melanoma-associated antigen recognized by HLA-DR11-restricted CD4(+) Th1 cells. Epitope mapping analysis showed that the DRG1248-268 epitope of DRG-1 was required for T cell recognition. Reverse transcription-polymerase chain reaction revealed that DRG-1 was highly expressed in melanoma cell lines but not in normal tissues. DRG-1 knockdown by lentiviral-based shRNA suppressed melanoma cell proliferation and soft agar colony formation. Taken together, these data suggest that DRG-1 plays an important role in melanoma cell growth and transformation, indicating that DRG1 may represent a novel target for CD4(+) T cell-mediated immunotherapy in melanoma.

[Cost assessment for endoscopic procedures in the German diagnosis-related-group (DRG) system - 5 year cost data analysis of the German Society of Gastroenterology project].

PubMed

Rathmayer, Markus; Heinlein, Wolfgang; Reiß, Claudia; Albert, Jörg G; Akoglu, Bora; Braun, Martin; Brechmann, Thorsten; Gölder, Stefan K; Lankisch, Tim; Messmann, Helmut; Schneider, Arne; Wagner, Martin; Dollhopf, Markus; Gundling, Felix; Röhling, Michael; Haag, Cornelie; Dohle, Ines; Werner, Sven; Lammert, Frank; Fleßa, Steffen; Wilke, Michael H; Schepp, Wolfgang; Lerch, Markus M

2017-10-01

Background  In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods  To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; § 21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results  Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion  For the first time this catalogue for endoscopic procedure-tiers, based on § 21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses. © Georg Thieme Verlag KG Stuttgart · New York.

[Impact of acupuncture to IGF-I expression in spared dorsal root ganglion of cats].

PubMed

Liu, Fen; Wang, Ting-Hua; Zhang, Yi; Hong, Sun-quan; Song, Xin-bo

2006-05-01

To explore the relationship between Insulin-like growth factor-I (IGF-I) and acupuncture promoting the spinal cord plasticity, the changes of IGF- I expressing in spared dorsal root ganglia (DRG,L6) after operation and acupuncture were investigated. 25 adult cats were divided into 5 groups: normal control group; 7th day and 14th day group after unilateral partial rhizotomy (unilateral L1-L5,L7-S2 DRG Were transected, but L6 DRG was spared); 7th day and 14th day group of acupuncture stimulating the spared DRG (electro-needle stimulation was performed by following unilateral partial root rhizotomy). Animals survived for 7 or 14 days after operation respectively. Unilateral L6 dorsal root ganglia of each group were made into 20 microm frozen sections. By immunohistochemistry ABC method, the sections were stained with specific IGF-I (1:200) antibody. The distribution and the number of IGF-I positive neurons in spared DRG (L6) that located the operated/acupuncture side of each animal were observed and counted. For 7th day group after acupuncture stiumlation, the number of IGF-I positive neurons of spared DRG of acupuncture side showed significantly more than that of 7th day operation group (P<0.05), but still less than that of normal group (P < 0.05); In 14th day group, IGF- I expression in neuron of L6 DRG also increased apparently more than that of 14th day operation group, with coming back to normal level. After acupuncture stimulating the spared DRG for 14 days, the numbers of IGF- I positive neurons in spared DRG increased significantly more than that of 7th day group after acupuncture (P<0.05). Acupuncture can significantly increase the number of IGF- I positive neurons. Our results indicate that the expression changes of IGF-I in spared DRG associate with acupuncture promoting the spinal cord plasticity.

Selective Radiofrequency Stimulation of the Dorsal Root Ganglion (DRG) as a Method for Predicting Targets for Neuromodulation in Patients With Post Amputation Pain: A Case Series.

PubMed

Hunter, Corey W; Yang, Ajax; Davis, Tim

2017-10-01

While spinal cord stimulation (SCS) has established itself as an accepted and validated treatment for neuropathic pain, there are a number of conditions where it has experienced less, long-term success: post amputee pain (PAP) being one of them. Dorsal root ganglion (DRG) stimulation has shown great promise, particularly in conditions where traditional SCS has fallen short. One major difference between DRG stimulation and traditional SCS is the ability to provide focal stimulation over targeted areas. While this may be a contributing factor to its superiority, it can also be a limitation insofar stimulating the wrong DRG(s) can lead to failure. This is particularly relevant in conditions like PAP where neuroplastic maladaptation occurs causing the pain to deviate from expected patterns, thus creating uncertainty and variability in predicting targets for stimulation. We propose selective radiofrequency (RF) stimulation of the DRG as a method for preoperatively predicting targets for neuromodulation in patients with PAP. We present four patients with PAP of the lower extremities. RF stimulation was used to selectively stimulate individual DRG's, creating areas of paresthesias to see which most closely correlated/overlapped with the painful area(s). RF stimulation to the DRG's that resulted in the desirable paresthesia coverage in the residual or the missing limb(s) was recorded as "positive." Trial DRG leads were placed based on the positive RF stimulation findings. In each patient, stimulating one or more DRG(s) produced paresthesias patterns that were contradictory to know dermatomal patterns. Upon completion of a one-week trial all four patients reported 60-90% pain relief, with coverage over the painful areas, and opted for permanent implant. Mapping the DRG via RF stimulation appears to provide improved accuracy for determining lead placement in the setting of PAP where pain patterns are known to deviate from conventional dermatomal mapping. © 2017 International Neuromodulation Society.

Blockade of anoctamin-1 in injured and uninjured nerves reduces neuropathic pain.

PubMed

García, Guadalupe; Martínez-Rojas, Vladimir A; Oviedo, Norma; Murbartián, Janet

2018-06-02

The aim of this study was to determine the participation of anoctamin-1 in 2 models of neuropathic pain in rats (L5/L6 spinal nerve ligation [SNL] and L5 spinal nerve transection [SNT]). SNL and SNT diminished withdrawal threshold in rats. Moreover, SNL up-regulated anoctamin-1 protein expression in injured L5 and uninjured L4 DRG whereas that it enhanced activating transcription factor 3 (ATF-3) and caspase-3 expression only in injured L5 DRG. In marked contrast, SNT enhanced ATF-3 and caspase-3, but not anoctamin-1, expression in injured L5 DRG but it did not modify anoctamin-1, ATF-3 nor caspase-3 expression in uninjured L4 DRG. Accordingly, repeated (3 times) intrathecal injection of the anoctamin-1 blocker T16A inh-A01 (0.1-1 µg) or MONNA (1-10 µg) partially reverted SNL-induced mechanical allodynia in a dose-dependent manner. In contrast, anoctamin-1 blockers only produced a modest effect in SNT-induced mechanical allodynia. Interestingly, intrathecal injection of T16A inh-A01 (1 µg) or MONNA (10 µg) prevented SNL-induced up-regulation of anoctamin-1, ATF-3 and caspase-3 in injured L5 DRG. Repeated intrathecal injection of T16A inh-A01 or MONNA also reduced SNT-induced up-regulation of ATF-3 in injured L5 DRG. In contrast, T16A inh-A01 and MONNA did not affect SNT-induced up-regulation of caspase-3 expression in L5 DRG. Likewise, gabapentin (100 µg) diminished SNL-induced up-regulation of anoctamin-1, ATF-3 and caspase-3 expression in injured L5 DRG. These data suggest that spinal anoctamin-1 in injured and uninjured DRG participates in the maintenance of neuropathic pain in rats. Our data also indicate that expression of anoctamin-1 in DRG is differentially regulated depending on the neuropathic pain model. Copyright © 2018. Published by Elsevier B.V.

Nanoparticle-Encapsulated Curcumin Inhibits Diabetic Neuropathic Pain Involving the P2Y12 Receptor in the Dorsal Root Ganglia

PubMed Central

Jia, Tianyu; Rao, Jingan; Zou, Lifang; Zhao, Shanhong; Yi, Zhihua; Wu, Bing; Li, Lin; Yuan, Huilong; Shi, Liran; Zhang, Chunping; Gao, Yun; Liu, Shuangmei; Xu, Hong; Liu, Hui; Liang, Shangdong; Li, Guilin

2018-01-01

Diabetic peripheral neuropathy results in diabetic neuropathic pain (DNP). Satellite glial cells (SGCs) enwrap the neuronal soma in the dorsal root ganglia (DRG). The purinergic 2 (P2) Y12 receptor is expressed on SGCs in the DRG. SGC activation plays an important role in the pathogenesis of DNP. Curcumin has anti-inflammatory and antioxidant properties. Because curcumin has poor metabolic stability in vivo and low bioavailability, nanoparticle-encapsulated curcumin was used to improve its targeting and bioavailability. In the present study, our aim was to investigate the effects of nanoparticle-encapsulated curcumin on DNP mediated by the P2Y12 receptor on SGCs in the rat DRG. Diabetic peripheral neuropathy increased the expression levels of the P2Y12 receptor on SGCs in the DRG and enhanced mechanical and thermal hyperalgesia in rats with diabetes mellitus (DM). Up-regulation of the P2Y12 receptor in SGCs in the DRG increased the production of pro-inflammatory cytokines. Up-regulation of interleukin-1β (IL-1β) and connexin43 (Cx43) resulted in mechanical and thermal hyperalgesia in rats with DM. The nanoparticle-encapsulated curcumin decreased up-regulated IL-1β and Cx43 expression and reduced levels of phosphorylated-Akt (p-Akt) in the DRG of rats with DM. The up-regulation of P2Y12 on SGCs and the up-regulation of the IL-1β and Cx43 in the DRG indicated the activation of SGCs in the DRG. The nano-curcumin treatment inhibited the activation of SGCs accompanied by its anti-inflammatory effect to decrease the up-regulated CGRP expression in the DRG neurons. Therefore, the nanoparticle-encapsulated curcumin treatment decreased the up-regulation of the P2Y12 receptor on SGCs in the DRG and decreased mechanical and thermal hyperalgesia in rats with DM. PMID:29422835

Drug Distribution into Peripheral Nerve.

PubMed

Liu, Houfu; Chen, Yan; Huang, Liang; Sun, Xueying; Fu, Tingting; Wu, Shengqian; Zhu, Xiaoyan; Zhen, Wei; Liu, Jihong; Lu, Gang; Cai, Wei; Yang, Ting; Zhang, Wandong; Yu, Xiaohong; Wan, Zehong; Wang, Jianfei; Summerfield, Scott G; Dong, Kelly; Terstappen, Georg C

2018-05-01

Little is known about the impact of the blood-nerve barrier (BNB) on drug distribution into peripheral nerves. In this study, we examined the peripheral nerve penetration in rats of 11 small-molecule drugs possessing diverse physicochemical and transport properties and ProTx-II, a tarantula venom peptide with molecular mass of 3826 Daltons. Each drug was administered as constant rate intravenous infusion for 6 hours (small molecules) or 24 hours (ProTx-II). Blood and tissues including brain, spinal cord, sciatic nerve, and dorsal root ganglion (DRG) were collected for drug concentration measurements. Unbound fractions of a set of compounds were determined by equilibrium dialysis method in rat blood, brains, spinal cords, sciatic nerves, and DRG. We also investigated the influence of N -[4-[2-(6,7-dimethoxy-3,4-dihydro-1 H -isoquinolin-2-yl)ethyl]phenyl]-5-methoxy-9-oxo-10 H -acridine-4-carboxamide (GF120918), a P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) inhibitor, on the peripheral nerve and central nervous system (CNS) tissue penetration of imatinib. We found that: 1) the unbound fraction in brain tissue homogenate highly correlates with that in the spinal cord, sciatic nerve, and DRG for a set of compounds and thus provides a good surrogate for spinal cord and peripheral nerve tissues, 2) small-molecule drugs investigated can penetrate the DRG and sciatic nerve, 3) P-gp and BCRP have a limited impact on the distribution of small-molecule drugs into peripheral nerves, and 4) DRG is permeable to ProTx-II, but its distribution into sciatic nerve and CNS tissues is restricted. These results demonstrate that small-molecule drugs investigated can penetrate peripheral nerve tissues, and P-gp/BCRP may not be a limiting factor at the BNB. Biologics as large as ProTx-II can access the DRG but not sciatic nerve and CNS tissues. Copyright © 2018 by The American Society for Pharmacology and Experimental Therapeutics.

Advanced oxidation protein products sensitized the transient receptor potential vanilloid 1 via NADPH oxidase 1 and 4 to cause mechanical hyperalgesia.

PubMed

Ding, Ruoting; Jiang, Hui; Sun, Baihui; Wu, Xiaoliang; Li, Wei; Zhu, Siyuan; Liao, Congrui; Zhong, Zhaoming; Chen, Jianting

2016-12-01

Oxidative stress is a possible pathogenesis of hyperalgesia. Advanced oxidation protein products (AOPPs), a new family of oxidized protein compounds, have been considered as a novel marker of oxidative stress. However, the role of AOPPs in the mechanism of hyperalgesia remains unknown. Our study aims to investigate whether AOPPs have an effect on hyperalgesia and the possible underlying mechanisms. To identify the AOPPs involved, we induced hyperalgesia in rats by injecting complete Freund's adjuvant (CFA) in hindpaw. The level of plasma AOPPs in CFA-induced rats was 1.6-fold in comparison with what in normal rats (P<0.05). After intravenous injection of AOPPs-modified rat serum albumin (AOPPs-RSA) in Sprague-Dawley rats, the paw mechanical thresholds, measured by the electronic von Frey system, significantly declined. Immunofluorescence staining indicated that AOPPs increased expressions of NADPH oxidase 1 (Nox1), NADPH oxidase 4 (Nox4), transient receptor potential vanilloid 1 (TRPV1) and calcitonin gene-related peptide (CGRP) in the dorsal root ganglia (DRG) tissues. In-vitro studies were performed on primary DRG neurons which were obtained from both thoracic and lumbar DRG of rats. Results indicated that AOPPs triggered reactive oxygen species (ROS) production in DRG neurons, which were significantly abolished by ROS scavenger N-acetyl-l-cysteine (NAC) and small-interfering RNA (siRNA) silencing of Nox1 or Nox4. The expressions of Nox1, Nox4, TRPV1 and CGRP were significantly increased in AOPPs-induced DRG neurons. And relevant siRNA or inhibitors notably suppressed the expressions of these proteins and the calcium influxes in AOPPs-induced DRG neurons. In conclusion, AOPPs increased significantly in CFA-induced hyperalgesia rats and they activated Nox1/Nox4-ROS to sensitize TRPV1-dependent Ca2+ influx and CGRP release which led to inducing mechanical hyperalgesia. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.

Allotransplanted DRG neurons or Schwann cells affect functional recovery in a rodent model of sciatic nerve injury.

PubMed

Dayawansa, Samantha; Wang, Ernest W; Liu, Weimin; Markman, John D; Gelbard, Harris A; Huang, Jason H

2014-11-01

In this study, the functional recoveries of Sprague-Dawley rats following repair of a complete sciatic nerve transection using allotransplanted dorsal root ganglion (DRG) neurons or Schwann cells were examined using a number of outcome measures. Four groups were compared: (1) repair with a nerve guide conduit seeded with allotransplanted Schwann cells harvested from Wistar rats, (2) repair with a nerve guide conduit seeded with DRG neurons, (3) repair with solely a nerve guide conduit, and (4) sham-surgery animals where the sciatic nerve was left intact. The results corroborated our previous reported histology findings and measures of immunogenicity. The Wistar-DRG-treated group achieved the best recovery, significantly outperforming both the Wistar-Schwann group and the nerve guide conduit group in the Von Frey assay of touch response (P < 0.05). Additionally, Wistar-DRG and Wistar-Schwann seeded repairs showed lower frequency and severity in an autotomy measure of the self-mutilation of the injured leg because of neuralgia. These results suggest that in complete peripheral nerve transections, surgical repair using nerve guide conduits with allotransplanted DRG and Schwann cells may improve recovery, especially DRG neurons, which elicit less of an immune response.

[Is surgical education associated with additional costs? A controlled economic study on the German DRG System for primary TKA].

PubMed

Göbel, P; Piesche, K; Randau, T; Wimmer, M D; Wirtz, D C; Gravius, S

2013-04-01

Total knee arthroplasty (TKA) is one of the most common procedures in orthopaedic surgery, the cost of surgical training has as yet not been quantified. In a pilot study, we investigated the economic impact of surgical training under DRG system influences, analysing the cost-proceeds structure in surgical training for orthopaedic residents. Consecutive TKAs were performed by the most educated surgeon (Group A) having implanted ≥ 1000 TKAs, another attending (Group B) with ≥ 200 TKAs and a resident (Group C) having assisted in 25 TKAs (n = 30 patients per Group A-C). All patients were embedded in a standardised clinical pathway. By analysing the costs parameters such as numbers of blood transfusions, the operating time and the length of stay in the hospital we investigated the health care-related costs matched to the DRG-based financial refunding. Data were analysed after undergoing a analysis of variance followed by a post-hoc Scheffé procedure. On the one hand the resident generated additional costs of 1111,7 ± 97 € in comparison to the Group A surgeon and 1729,8 ± 152 € compared to the attending Group B (p > 0,05), these were generated by longer stay in hospital, longer operation time and higher need of resources. On the other hand there were significantly higher proceeds of the Group C in comparison to the attending Group B and also to Group A: 474,78 ± 82 € vs. A and 150,54 ± 52 € vs. Group B (p < 0,05). This was generated both by a higher patient clinical level of complexity (PCCL) and increased complication rates resulting in a consecutively augmented profit by grouping these patients to a more lucrative DRG. Overall the deficit per patient treated by the resident is 637 ± 77 € vs. Group A and 1579,3 ± 137 € vs. Group B (p > 0,05). The German DRG matrix results in higher profits accounted to the learning surgeon by increased PCCL relevant status and grouping the case to a more profitable DRG. Hereby, the additional costs are only partly redeemed. Surgical education of residents is associated with additional costs for the hospital. These costs have to be redeemed to allow good surgical training for hospitals having good teaching conditions. Georg Thieme Verlag KG Stuttgart · New York.

[Minimally invasive surgery and the economics of it. Can minimally invasive surgery be cost efficient from a business point of view?].

PubMed

Ritz, J P; Stufler, M; Buhr, H J

2007-06-01

Minimally invasive surgery (MIS) is now accepted as equally valid as the use of a standard access in some areas of surgery. It is not possible to decide whether this access is economically worthwhile and if so for whom without a full economic cost-benefit analysis, which must take account of the hospital's own characteristics in addition to the cost involved for surgery, staff, infrastructure and administration. In summary, the main economic advantage of MIS lies in the patient-related early postoperative results, while the main disadvantage is that the operative material costs are higher. At present, the payment made for each procedure performed under the DRG system includes 14-17% of the total cost for materials, regardless of the access route and of the technical sophistication of the operation. The actual material costs are greater by a factor of 2-50 for MIS than for a conventional procedure. The task of the hospital is thus to lower the costs for material and infrastructure; that of industry is to offer less expensive alternatives; and that of our politicians, to implement better remuneration of the material costs.

Dorsal Root Ganglion (DRG) Stimulation in the Treatment of Phantom Limb Pain (PLP).

PubMed

Eldabe, Sam; Burger, Katja; Moser, Heinrich; Klase, Daniel; Schu, Stefan; Wahlstedt, Anders; Vanderick, Bernard; Francois, Eric; Kramer, Jeffery; Subbaroyan, Jeyakumar

2015-10-01

Phantom limb pain (PLP) is a neuropathic condition in which pain is perceived as arising from an amputated limb. PLP is distinct from, although associated with, pain in the residual limb and nonpainful phantom sensations of the missing limb. Its treatment is extremely challenging; pharmaceutical options, while commonly employed, may be insufficient or intolerable. Neuromodulatory interventions such as spinal cord stimulation have generated mixed results and may be limited by poor somatotopic specificity. It was theorized that dorsal root ganglion (DRG) neuromodulation may be more effective. Patients trialed a DRG neurostimulation system for their PLP and were subsequently implanted if results were positive. Retrospective chart review was completed, including pain ratings on a 100-mm visual analogue scale (VAS) and patient-reported outcomes. Across eight patients, the average baseline pain rating was 85.5 mm. At follow-up (mean of 14.4 months), pain was rated at 43.5 mm. Subjective ratings of quality of life and functional capacity improved. Some patients reduced or eliminated pain medications. Patients reported precise concordance of the paresthesia with painful regions, including in their phantom limbs; in one case, stimulation eliminated PLP as well as nonpainful phantom sensations. Three patients experienced a diminution of pain relief, despite good initial outcomes. DRG neuromodulation may be an effective tool in treating this pain etiology. Clinical outcomes in this report support recent converging evidence suggesting that the DRG may be the site of PLP generation and/or maintenance. Further research is warranted to elucidate mechanisms and optimal treatment pathways. © 2015 International Neuromodulation Society.

Possible role of glial cells in the onset and progression of Lyme neuroborreliosis

PubMed Central

Ramesh, Geeta; Borda, Juan T; Gill, Amy; Ribka, Erin P; Morici, Lisa A; Mottram, Peter; Martin, Dale S; Jacobs, Mary B; Didier, Peter J; Philipp, Mario T

2009-01-01

Background Lyme neuroborreliosis (LNB) may present as meningitis, cranial neuropathy, acute radiculoneuropathy or, rarely, as encephalomyelitis. We hypothesized that glia, upon exposure to Borrelia burgdorferi, the Lyme disease agent, produce inflammatory mediators that promote the acute cellular infiltration of early LNB. This inflammatory context could potentiate glial and neuronal apoptosis. Methods We inoculated live B. burgdorferi into the cisterna magna of rhesus macaques and examined the inflammatory changes induced in the central nervous system (CNS), and dorsal root nerves and ganglia (DRG). Results ELISA of the cerebrospinal fluid (CSF) showed elevated IL-6, IL-8, CCL2, and CXCL13 as early as one week post-inoculation, accompanied by primarily lymphocytic and monocytic pleocytosis. In contrast, onset of the acquired immune response, evidenced by anti-B. burgdorferi C6 serum antibodies, was first detectable after 3 weeks post-inoculation. CSF cell pellets and CNS tissues were culture-positive for B. burgdorferi. Histopathology revealed signs of acute LNB: severe multifocal leptomeningitis, radiculitis, and DRG inflammatory lesions. Immunofluorescence staining and confocal microscopy detected B. burgdorferi antigen in the CNS and DRG. IL-6 was observed in astrocytes and neurons in the spinal cord, and in neurons in the DRG of infected animals. CCL2 and CXCL13 were found in microglia as well as in endothelial cells, macrophages and T cells. Importantly, the DRG of infected animals showed significant satellite cell and neuronal apoptosis. Conclusion Our results support the notion that innate responses of glia to B. burgdorferi initiate/mediate the inflammation seen in acute LNB, and show that neuronal apoptosis occurs in this context. PMID:19706181

[Influence of functional dependence on the case mix in a geriatric unit].

PubMed

González-Guerrero, José Luis; Alonso-Fernández, Teresa; Gálvez, Noemí; García-Mayolín, Nieves

2008-01-01

To determine the influence of pre-admission functional status on the case mix in a geriatric unit, after adjustment by the diagnosis-related groups (DRG) patient classification system. We performed a retrospective observational study in patients admitted to the geriatric unit of a general hospital over a 2-year period. Patients with a length of stay of less than 2 days and transfers from other medical services and hospitals were excluded. The following data were obtained from the minimum data set and from chart review: age, sex, place of residence before admission, Charlson comorbidity index, pre-admission functional status and mobility, cognitive status, length of hospital stay, rate of in-hospital mortality, and the DRG (and DRG weight) for each patient. A total of 1065 patients were included in this study. The mean age was 84 years (64-102), and 64% were women. Patients with lower functional status were more often female (67.1 vs 55.8%; P< .01), more frequently admitted from nursing homes (35.8 vs 14.7%; P< .01) and had higher mortality (19.3 vs 10.1%; P< .01). These patients also had a higher mean length of stay (12.7 vs 11.9), higher comorbidity scores (P< .01), greater cognitive impairment (P< .01) and higher DRG weight (P=.03). Once the more frequent DRG were reviewed, patients who were dependent had a greater number of respiratory infections and renal problems and had fewer cerebrovascular diseases. Some clinical characteristics differ in patients with functional dependence. This finding could influence the clinical management of medical services that treat more dependent patients.

[Effect of partial ganglionectomy and acupuncture on culturing spared DRG in vitro].

PubMed

Wang, Te-Wei; Wang, Ting-Hua; Zhou, Xue; Zhang, Lian-Shuang; Xu, Xin-Yun

2005-09-01

To explore the effect of partial dorsal root rhizotomy and Acup on culturing dorsal root ganglion(DRG) in vitro. Ten adult cats were divided into 2 groups: normal control group; Acup spared DRG 7 d group, in which bilateral L1-L5, L7-S2 DRG were removed; and L6DRG were spared; then unilaterally two sets of acupoints [Zusanlily (St. 36) and Xuanzhong (G. B. 39): Futu (St. 32) and Sanyinjiao (Sp. 6) located in the distribution area of spinal nerve L6] were electro-stimulated alternatively 30 min everyday by electro-needling. Five cats were used in every group. Bilateral L6 DRGs of every group were taken out on the condition of asepsis and were cultured respectively in vitro. Cultures were terminated after day 7. Then the cultured cells were stained under the same condition using specific NSE (1 : 200) antibody, a neuron-specific marker, by the immunohistochemistry ABC method. The neurite length was measured by micro-measured ruler in upside-down light microscope on the 1st, 3rd, 5th, 7th day. Immunocytochemical staining revealed that over 95% cells were NSE positive cells which were the typical neuron of DRG in vitro; on the 1st, 3rd, 5th, 7th day, the average neurite length of the normal group was shorter than that of the spared DRG group(P < 0. 05), and the spared DRG group's was shorter than the Acup group's at each time stage (P < 0.05). These results indicated that DRG had plasticity and acupuncture probably promoted the plasticity, which were probably in close relation with the spinal plasticity.

Pyruvate Dehydrogenase Kinase-mediated Glycolytic Metabolic Shift in the Dorsal Root Ganglion Drives Painful Diabetic Neuropathy*

PubMed Central

Rahman, Md Habibur; Jha, Mithilesh Kumar; Kim, Jong-Heon; Nam, Youngpyo; Lee, Maan Gee; Go, Younghoon; Harris, Robert A.; Park, Dong Ho; Kook, Hyun; Lee, In-Kyu; Suk, Kyoungho

2016-01-01

The dorsal root ganglion (DRG) is a highly vulnerable site in diabetic neuropathy. Under diabetic conditions, the DRG is subjected to tissue ischemia or lower ambient oxygen tension that leads to aberrant metabolic functions. Metabolic dysfunctions have been documented to play a crucial role in the pathogenesis of diverse pain hypersensitivities. However, the contribution of diabetes-induced metabolic dysfunctions in the DRG to the pathogenesis of painful diabetic neuropathy remains ill-explored. In this study, we report that pyruvate dehydrogenase kinases (PDK2 and PDK4), key regulatory enzymes in glucose metabolism, mediate glycolytic metabolic shift in the DRG leading to painful diabetic neuropathy. Streptozotocin-induced diabetes substantially enhanced the expression and activity of the PDKs in the DRG, and the genetic ablation of Pdk2 and Pdk4 attenuated the hyperglycemia-induced pain hypersensitivity. Mechanistically, Pdk2/4 deficiency inhibited the diabetes-induced lactate surge, expression of pain-related ion channels, activation of satellite glial cells, and infiltration of macrophages in the DRG, in addition to reducing central sensitization and neuroinflammation hallmarks in the spinal cord, which probably accounts for the attenuated pain hypersensitivity. Pdk2/4-deficient mice were partly resistant to the diabetes-induced loss of peripheral nerve structure and function. Furthermore, in the experiments using DRG neuron cultures, lactic acid treatment enhanced the expression of the ion channels and compromised cell viability. Finally, the pharmacological inhibition of DRG PDKs or lactic acid production substantially attenuated diabetes-induced pain hypersensitivity. Taken together, PDK2/4 induction and the subsequent lactate surge induce the metabolic shift in the diabetic DRG, thereby contributing to the pathogenesis of painful diabetic neuropathy. PMID:26769971

Overexpression of GDNF in the uninjured DRG exerts analgesic effects on neuropathic pain following segmental spinal nerve ligation in mice.

PubMed

Takasu, Kumiko; Sakai, Atsushi; Hanawa, Hideki; Shimada, Takashi; Suzuki, Hidenori

2011-11-01

Glial cell line-derived neurotrophic factor (GDNF), a survival-promoting factor for a subset of nociceptive small-diameter neurons, has been shown to exert analgesic effects on neuropathic pain. However, its detailed mechanisms of action are still unknown. In the present study, we investigated the site-specific analgesic effects of GDNF in the neuropathic pain state using lentiviral vector-mediated GDNF overexpression in mice with left fifth lumbar (L5) spinal nerve ligation (SNL) as a neuropathic pain model. A lentiviral vector expressing both GDNF and enhanced green fluorescent protein (EGFP) was constructed and injected into the left dorsal spinal cord, uninjured fourth lumbar (L4) dorsal root ganglion (DRG), injured L5 DRG, or plantar skin of mice. In SNL mice, injection of the GDNF-EGFP-expressing lentivirus into the dorsal spinal cord or uninjured L4 DRG partially but significantly reduced the mechanical allodynia in association with an increase in GDNF protein expression in each virus injection site, whereas injection into the injured L5 DRG or plantar skin had no effects. These results suggest that GDNF exerts its analgesic effects in the neuropathic pain state by acting on the central terminals of uninjured DRG neurons and/or on the spinal cells targeted by the uninjured DRG neurons. This article shows that GDNF exerts its analgesic effects on neuropathic pain by acting on the central terminals of uninjured DRG neurons and/or on the spinal cells targeted by these neurons. Therefore, research focusing on these GDNF-dependent neurons in the uninjured DRG would provide a new strategy for treating neuropathic pain. Copyright © 2011 American Pain Society. Published by Elsevier Inc. All rights reserved.

GDNF and NGF family members and receptors in human fetal and adult spinal cord and dorsal root ganglia.

PubMed

Josephson, A; Widenfalk, J; Trifunovski, A; Widmer, H R; Olson, L; Spenger, C

2001-11-12

We describe the expression of mRNA encoding ligands and receptors of members of the GDNF family and members of the neurotrophin family in the adult human spinal cord and dorsal root ganglia (DRG). Fetal human spinal cord and ganglia were investigated for the presence of ligands and receptors of the neurotrophin family. Tissues were collected from human organ donors and after routine elective abortions. Messenger RNA was found encoding RET, GFR alpha-1, BDNF, trkB, and trkC in the adult human spinal cord and BDNF, NT-3, p75, trkB, and trkC in the fetal human spinal cord. The percentage of adult human DRG cells expressing p75, trkA, trkB, or trkC was 57, 46, 29, and 24%, respectively, and that of DRG cells expressing RET, GFR alpha-1, GFR alpha-2, or GFR alpha-3 was 79, 20, 51, and 32%, respectively. GFR alpha-2 was expressed selectively in small, GFR alpha-3 principally in small and GFR alpha-1 and RET in both large and small adult human DRG neurons. p75 and trkB were expressed by a wide range of DRG neurons while trkA was expressed in most small diameter and trkC primarily in large DRG neurons. Fetal DRG cells were positive for the same probes as adult DRG cells except for NT-3, which was only found in fetal DRG cells. Messenger RNA species only expressed at detectable levels in fetal but not adult spinal cord tissues included GDNF, GFR alpha-2, NT-3, and p75. Notably, GFR alpha-2, which is expressed in the adult rat spinal cord, was not found in the adult human spinal cord. Copyright 2001 Wiley-Liss, Inc.

DRG axon elongation and growth cone collapse rate induced by Sema3A are differently dependent on NGF concentration.

PubMed

Kaselis, Andrius; Treinys, Rimantas; Vosyliūtė, Rūta; Šatkauskas, Saulius

2014-03-01

Regeneration of embryonic and adult dorsal root ganglion (DRG) sensory axons is highly impeded when they encounter neuronal growth cone-collapsing factor semaphorin3A (Sema3A). On the other hand, increasing evidence shows that DRG axon's regeneration can be stimulated by nerve growth factor (NGF). In this study, we aimed to evaluate whether increased NGF concentrations can counterweight Sema3A-induced inhibitory responses in 15-day-old mouse embryo (E15) DRG axons. The DRG explants were grown in Neurobasal-based medium with different NGF concentrations ranging from 0 to 100 ng/mL and then treated with Sema3A at constant 10 ng/mL concentration. To evaluate interplay between NGF and Sema3A number of DRG axons, axon outgrowth distance and collapse rate were measured. We found that the increased NGF concentrations abolish Sema3A-induced inhibitory effect on axon outgrowth, while they have no effect on Sema3A-induced collapse rate.

Coupled Activation of Primary Sensory Neurons Contributes to Chronic Pain.

PubMed

Kim, Yu Shin; Anderson, Michael; Park, Kyoungsook; Zheng, Qin; Agarwal, Amit; Gong, Catherine; Saijilafu; Young, LeAnne; He, Shaoqiu; LaVinka, Pamela Colleen; Zhou, Fengquan; Bergles, Dwight; Hanani, Menachem; Guan, Yun; Spray, David C; Dong, Xinzhong

2016-09-07

Primary sensory neurons in the DRG play an essential role in initiating pain by detecting painful stimuli in the periphery. Tissue injury can sensitize DRG neurons, causing heightened pain sensitivity, often leading to chronic pain. Despite the functional importance, how DRG neurons function at a population level is unclear due to the lack of suitable tools. Here we developed an imaging technique that allowed us to simultaneously monitor the activities of >1,600 neurons/DRG in live mice and discovered a striking neuronal coupling phenomenon that adjacent neurons tend to activate together following tissue injury. This coupled activation occurs among various neurons and is mediated by an injury-induced upregulation of gap junctions in glial cells surrounding DRG neurons. Blocking gap junctions attenuated neuronal coupling and mechanical hyperalgesia. Therefore, neuronal coupling represents a new form of neuronal plasticity in the DRG and contributes to pain hypersensitivity by "hijacking" neighboring neurons through gap junctions. Copyright © 2016 Elsevier Inc. All rights reserved.

The Effects of IGF-1 on Trk Expressing DRG Neurons with HIV-gp120- Induced Neurotoxicity.

PubMed

Li, Hao; Liu, Zhen; Chi, Heng; Bi, Yanwen; Song, Lijun; Liu, Huaxiang

2016-01-01

HIV envelope glycoprotein gp120 is the main protein that causes HIVassociated sensory neuropathy. However, the underlying mechanisms of gp120-induced neurotoxicity are still unclear. There are lack effective treatments for relieving HIV-related neuropathic symptoms caused by gp120-induced neurotoxicity. In the present study, tyrosine kinase receptor (Trk)A, TrkB, and TrkC expression in primary cultured dorsal root ganglion (DRG) neurons with gp120-induced neurotoxicity was investigated. The effects of IGF-1 on distinct Trk-positive DRG neurons with gp120-induced neurotoxicity were also determined. The results showed that gp120 not only dose-dependently induced DRG neuronal apoptosis and inhibited neuronal survival and neurite outgrowth, but also decreased distinct Trk expression levels. IGF-1 rescued DRG neurons from apoptosis and improved neuronal survival of gp120 neurotoxic DRG neurons in vitro. IGF-1 also improved TrkA and TrkB, but not TrkC, expression in gp120 neurotoxic conditions. The effects of IGF-1 could be blocked by preincubation with the phosphatidylinositol 3-kinase (PI3K) inhibitor LY294002. These results suggested that gp120 may have a wide range of neurotoxicity on different subpopulations of DRG neurons, while IGF-1 might only relieve some subpopulations of DRG neurons with gp120-induced neurotoxicity. These data provide novel information of mechanisms of gp120 neurotoxicity on primary sensory neurons and the potential therapeutic effects of IGF-1 on gp120-induced neurotoxicity.

DRG benchmarking: analysis of service structures and -differences in dermatology departments.

PubMed

Fürstenberg, Torsten; Gierling, Patrick; Irps, Sebastian; Gollnick, Harald; Kaufmann, Roland; Stadler, Rudolf; Rompel, Rainer; Hensen, Peter

2014-07-01

In the context of DRG-based hospital funding, the analysis of services provided in dermatologic inpatient care is highly relevant. We analyzed and compared clinical service structures and varieties in dermatologic hospitals through a benchmarking technique. For this multicenter cross-sectional study, routine data from 46 German dermatologic clinics and departments were collected, processed, and analyzed. In total, 95 257 data sets from 2011 were available. The data were grouped according to the G-DRG-system 2013 version. The average length of stay for all cases was 6.3 days (DRG "inliers": 5.7 days), and average patient age was 52 years. In total, 55 % of all cases were grouped to medical, 45 % to surgical DRGs. 71 % of all hospitals provide services within or close to this average value (± 10 %). No association was found between the number of hospital beds and the variety of clinical services provided in our sample. We found huge varieties in several parameters assessing the coding quality. The results reflect the heterogeneous reality in German inpatient dermatology. The varieties in dermatologic service range still depend on patient-related factors as well as infrastructural conditions and the resources available at each site. © 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.

Differential expression of ryanodine receptor isoforms after spinal cord injury.

PubMed

Pelisch, Nicolas; Gomes, Cynthia; Nally, Jacqueline M; Petruska, Jeffrey C; Stirling, David P

2017-11-01

Ryanodine receptors (RyRs) are highly conductive intracellular Ca 2+ release channels and are widely expressed in many tissues, including the central nervous system. RyRs have been implicated in intracellular Ca 2+ overload which can drive secondary damage following traumatic injury to the spinal cord (SCI), but the spatiotemporal expression of the three isoforms of RyRs (RyR1-3) after SCI remains unknown. Here, we analyzed the gene and protein expression of RyR isoforms in the murine lumbar dorsal root ganglion (DRG) and the spinal cord lesion site at 1, 2 and 7 d after a mild contusion SCI. Quantitative RT PCR analysis revealed that RyR3 was significantly increased in lumbar DRGs and at the lesion site at 1 and 2 d post contusion compared to sham (laminectomy only) controls. Additionally, RyR2 expression was increased at 1 d post injury within the lesion site. RyR2 and -3 protein expression was localized to lumbar DRG neurons and their spinal projections within the lesion site acutely after SCI. In contrast, RyR1 expression within the DRG and lesion site remained unaltered following trauma. Our study shows that SCI initiates acute differential expression of RyR isoforms in DRG and spinal cord. Copyright © 2017 Elsevier B.V. All rights reserved.

42 CFR 476.84 - Changes as a result of DRG validation.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false Changes as a result of DRG validation. 476.84... DRG validation. A provider or practitioner may obtain a review by a QIO under part 473 of this chapter... result of QIO validation activities. ...

Neto2 Assembles with Kainate Receptors in DRG Neurons during Development and Modulates Neurite Outgrowth in Adult Sensory Neurons.

PubMed

Vernon, Claire G; Swanson, Geoffrey T

2017-03-22

Peripheral sensory neurons in the dorsal root ganglia (DRG) are the initial transducers of sensory stimuli, including painful stimuli, from the periphery to central sensory and pain-processing centers. Small- to medium-diameter non-peptidergic neurons in the neonatal DRG express functional kainate receptors (KARs), one of three subfamilies of ionotropic glutamate receptors, as well as the putative KAR auxiliary subunit Neuropilin- and tolloid-like 2 (Neto2). Neto2 alters recombinant KAR function markedly but has yet to be confirmed as an auxiliary subunit that assembles with and alters the function of endogenous KARs. KARs in neonatal DRG require the GluK1 subunit as a necessary constituent, but it is unclear to what extent other KAR subunits contribute to the function and proposed roles of KARs in sensory ganglia, which include promotion of neurite outgrowth and modulation of glutamate release at the DRG-dorsal horn synapse. In addition, KARs containing the GluK1 subunit are implicated in modes of persistent but not acute pain signaling. We show here that the Neto2 protein is highly expressed in neonatal DRG and modifies KAR gating in DRG neurons in a developmentally regulated fashion in mice. Although normally at very low levels in adult DRG neurons, Neto2 protein expression can be upregulated via MEK/ERK signaling and after sciatic nerve crush and Neto2 -/- neurons from adult mice have stunted neurite outgrowth. These data confirm that Neto2 is a bona fide KAR auxiliary subunit that is an important constituent of KARs early in sensory neuron development and suggest that Neto2 assembly is critical to KAR modulation of DRG neuron process outgrowth. SIGNIFICANCE STATEMENT Pain-transducing peripheral sensory neurons of the dorsal root ganglia (DRG) express kainate receptors (KARs), a subfamily of glutamate receptors that modulate neurite outgrowth and regulate glutamate release at the DRG-dorsal horn synapse. The putative KAR auxiliary subunit Neuropilin- and tolloid-like 2 (Neto2) is also expressed in DRG. We show here that it is a developmentally downregulated but dynamic component of KARs in these neurons, that it contributes to regulated neurite regrowth in adult neurons, and that it is increased in adult mice after nerve injury. Our data confirm Neto2 as a KAR auxiliary subunit and expand our knowledge of the molecular composition of KARs in nociceptive neurons, a key piece in understanding the mechanistic contribution of KAR signaling to pain-processing circuits. Copyright © 2017 the authors 0270-6474/17/373352-12$15.00/0.

Peritonectomy and hyperthermic intraperitoneal chemotherapy: cost analysis and sustainability.

PubMed

Bagnoli, Pietro F; Cananzi, F C M; Brocchi, A; Ardito, A; Strada, D; Cozzaglio, L; Mussi, C; Brusa, S; Carlino, C; Borrelli, B; Alemanno, F; Quagliuolo, V

2015-03-01

Malignancies of the peritoneum remain a challenge in any hospital that accepts to manage them, due not only to difficulties associated with the complexity of the procedures involved but also the costs, which - in Italy and other countries that use a diagnosis-related group (DRG) system - are not adequately reimbursed. We analyzed data relative to 24 patients operated on between September 2010 and May 2013 with special regard to operating room expenditure, ICU stay, duration of hospitalization, and DRG reimbursement. The total costs per patient included clinical, operating room, procedure, pathology, imaging, ward care, allied healthcare, pharmaceutical, and ICU costs. Postoperative hospital stay, drugs and materials, and operating room occupancy were the main factors affecting the expenditure for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. We had a median hospitalization of 14 days, median ICU stay of 2.4 days, and median operating room occupancy of 585 min. The median expenditure for each case was € 21,744; the median reimbursement by the national health system € 8,375. In a DRG reimbursement system, the economic effort in the management of patients undergoing peritonectomy procedures may not be counterbalanced by adequate reimbursement. Joint efforts between medical and administration parties are mandatory to develop appropriate treatment protocols and keep down the costs. Copyright © 2014 Elsevier Ltd. All rights reserved.

Efficiency, cost-effectiveness and need of inversion in nutritional therapy. Importance of detecting and documenting undernutrition.

PubMed

Morán López, Jesús Manuel; Piedra León, María; Beneítez Moralejo, Belén; Enciso Izquierdo, Fidel Jesús; Luengo Pérez, Luis Miguel; Amado Señaris, José Antonio

2016-06-01

Disease Related Malnutrition (DRM) is highly prevalent in Spanish hospitals. WHO estimates that 20-40% of health-associated expenses are lost due to inefficiency. Demonstration that DRM is a component of inefficiency and hiring a specialist physician for its detection and treatment is cost-effective. Comparison between nutritional diagnosis and procedures detected and encoded at discharge using McNemar test. Recoding of 162 discharge reports including nutritional diagnoses and procedures. Determine changes on Case-Mix Index (IC), cost of procedure and cost procedure/DRG index. Comparison using T-student paired test. Only 10 of 162 diagnoses of malnutrition were coded in delivery statements (p < 0.001). After right codification, IC increased in 103,3 DRG points (p < 0.001). Consequently, procedure cost/DRG index was reduced in 978.81 € (p < 0.001). DRM is underdiagnosed in our hospital. DRM and nutritional procedures detection by a doctor specialist in clinical nutrition led to a reduction in cost procedure/DRG index of 16.8% of officially established by the Health System. Loss of 16.8% of health expenses, estimated in 424.785,15 € was described. Proper codification would have justified 343.291,2 € reimbursement just for nutritional diagnoses and processes. Both expenses were lost due to system's inefficiency. Those amounts are much higher than cost associated of hiring a specialist in clinical nutrition. Copyright © 2016 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.

Role of sodium ferulate in the nociceptive sensory facilitation of neuropathic pain injury mediated by P2X(3) receptor.

PubMed

Zhang, Aixia; Xu, Changshui; Liang, Shangdong; Gao, Yun; Li, Guilin; Wei, Jie; Wan, Fang; Liu, Shuangmei; Lin, Jiari

2008-12-01

Neuropathic pain usually is persistent and no effective treatment. ATP plays an important role in the initiation of pain. P2X(3) receptors are localized in the dorsal root ganglion (DRG) neurons and activated by extracellular ATP. Sodium ferulate (SF) is an active principle from Chinese herbal medicine and has anti-inflammatory activities. This study observed the effects of SF on the nociceptive facilitation of the primary sensory afferent after chronic constriction injury (CCI) mediated by P2X(3) receptor. In this study, the content of ATP in DRG neurons was measured by high-performance liquid chromatography (HPLC). P2X(3) agonist-activated currents in DRG neurons was recorded by the whole-cell patch-clamp skill. The expression of P2X(3) mRNA in DRG neurons was analyzed by in situ hybridization. The ATP content of DRG was increased after CCI. In CCI rats treated with SF, the content of ATP in DRG neurons was reduced. SF decreased the increment of P2X(3) agonist-activated currents and P2X(3) mRNA expression in DRG neurons during CCI. SF may inhibit the initiation of pain and primary afferent sensitization mediated by P2X(3) receptor during CCI.

Recombinant adeno-associated virus serotype 6 (rAAV2/6)-mediated gene transfer to nociceptive neurons through different routes of delivery

PubMed Central

Towne, Chris; Pertin, Marie; Beggah, Ahmed T; Aebischer, Patrick; Decosterd, Isabelle

2009-01-01

Background Gene transfer to nociceptive neurons of the dorsal root ganglia (DRG) is a promising approach to dissect mechanisms of pain in rodents and is a potential therapeutic strategy for the treatment of persistent pain disorders such as neuropathic pain. A number of studies have demonstrated transduction of DRG neurons using herpes simplex virus, adenovirus and more recently, adeno-associated virus (AAV). Recombinant AAV are currently the gene transfer vehicles of choice for the nervous system and have several advantages over other vectors, including stable and safe gene expression. We have explored the capacity of recombinant AAV serotype 6 (rAAV2/6) to deliver genes to DRG neurons and characterized the transduction of nociceptors through five different routes of administration in mice. Results Direct injection of rAAV2/6 expressing green fluorescent protein (eGFP) into the sciatic nerve resulted in transduction of up to 30% eGFP-positive cells of L4 DRG neurons in a dose dependant manner. More than 90% of transduced cells were small and medium sized neurons (< 700 μm2), predominantly colocalized with markers of nociceptive neurons, and had eGFP-positive central terminal fibers in the superficial lamina of the spinal cord dorsal horn. The efficiency and profile of transduction was independent of mouse genetic background. Intrathecal administration of rAAV2/6 gave the highest level of transduction (≈ 60%) and had a similar size profile and colocalization with nociceptive neurons. Intrathecal administration also transduced DRG neurons at cervical and thoracic levels and resulted in comparable levels of transduction in a mouse model for neuropathic pain. Subcutaneous and intramuscular delivery resulted in low levels of transduction in the L4 DRG. Likewise, delivery via tail vein injection resulted in relatively few eGFP-positive cells within the DRG, however, this transduction was observed at all vertebral levels and corresponded to large non-nociceptive cell types. Conclusion We have found that rAAV2/6 is an efficient vector to deliver transgenes to nociceptive neurons in mice. Furthermore, the characterization of the transduction profile may facilitate gene transfer studies to dissect mechanisms behind neuropathic pain. PMID:19737386

Localization and modulation of calcitonin gene-related peptide-receptor component protein-immunoreactive cells in the rat central and peripheral nervous systems.

PubMed

Ma, W; Chabot, J-G; Powell, K J; Jhamandas, K; Dickerson, I M; Quirion, R

2003-01-01

Calcitonin gene-related peptide (CGRP) is widely distributed in the central and peripheral nervous system. Its highly diverse biological activities are mediated via the G protein-coupled receptor that uniquely requires two accessory proteins for optimal function. CGRP receptor component protein (RCP) is a coupling protein necessary for CGRP-receptor signaling. In this study, we established the anatomical distribution of RCP in the rat central and peripheral nervous system and its relationship to CGRP immunoreactivity. RCP-immunoreactive (IR) perikarya are widely and selectively distributed in the cerebral cortex, septal nuclei, hippocampus, various hypothalamic nuclei, amygdala, nucleus colliculus, periaqueductal gray, parabrachial nuclei, locus coeruleus, cochlear nuclei, dorsal raphe nuclei, the solitary tractus nucleus and gracile nucleus, cerebellar cortex, various brainstem motor nuclei, the spinal dorsal and ventral horns. A sub-population of neurons in the dorsal root ganglia (DRG) and trigeminal ganglia were strongly RCP-IR. Overall, the localization of RCP-IR closely matched with that of CGRP-IR. We also determined whether RCP in DRG and dorsal horn neurons can be modulated by CGRP receptor blockade and pain-related pathological stimuli. The intrathecal injection of the antagonist CGRP(8-37) markedly increased RCP expression in the lumbar DRG and spinal dorsal horn. Carrageenan-induced plantar inflammation produced a dramatic bilateral increase in RCP expression in the dorsal horn while a partial sciatic nerve ligation reduced RCP expression in the ipsilateral superficial dorsal horn. Our data suggest that the distribution of RCP immunoreactivity is closely matched with CGRP immunoreactivity in most of central and peripheral nervous systems. The co-localization of RCP and CGRP in motoneurons and primary sensory neurons suggests that CGRP has an autocrine or paracrine effect on these neurons. Moreover, our data also suggest that RCP expression in DRG and spinal cord can be modulated during CGRP receptor blockade, inflammation or neuropathic pain and this CGRP receptor-associated protein is dynamically regulated.

Inflammation in the Pathogenesis of Lyme Neuroborreliosis

PubMed Central

Ramesh, Geeta; Didier, Peter J.; England, John D.; Santana-Gould, Lenay; Doyle-Meyers, Lara A.; Martin, Dale S.; Jacobs, Mary B.; Philipp, Mario T.

2016-01-01

Lyme neuroborreliosis, caused by the spirochete Borrelia burgdorferi, affects both peripheral and central nervous systems. We assessed a causal role for inflammation in Lyme neuroborreliosis pathogenesis by evaluating the induced inflammatory changes in the central nervous system, spinal nerves, and dorsal root ganglia (DRG) of rhesus macaques that were inoculated intrathecally with live B. burgdorferi and either treated with dexamethasone or meloxicam (anti-inflammatory drugs) or left untreated. ELISA of cerebrospinal fluid showed significantly elevated levels of IL-6, IL-8, chemokine ligand 2, and CXCL13 and pleocytosis in all infected animals, except dexamethasone-treated animals. Cerebrospinal fluid and central nervous system tissues of infected animals were culture positive for B. burgdorferi regardless of treatment. B. burgdorferi antigen was detected in the DRG and dorsal roots by immunofluorescence staining and confocal microscopy. Histopathology revealed leptomeningitis, vasculitis, and focal inflammation in the central nervous system; necrotizing focal myelitis in the cervical spinal cord; radiculitis; neuritis and demyelination in the spinal roots; and inflammation with neurodegeneration in the DRG that was concomitant with significant neuronal and satellite glial cell apoptosis. These changes were absent in the dexamethasone-treated animals. Electromyography revealed persistent abnormalities in F-wave chronodispersion in nerve roots of a few infected animals; which were absent in dexamethasone-treated animals. These results suggest that inflammation has a causal role in the pathogenesis of acute Lyme neuroborreliosis. PMID:25892509

Pulsed Radiofrequency to the Dorsal Root Ganglion in Acute Herpes Zoster and Postherpetic Neuralgia.

PubMed

Kim, Koohyun; Jo, Daehyun; Kim, EungDon

2017-03-01

Latent varicella zoster virus reactivates mainly in sensory ganglia such as the dorsal root ganglion (DRG) or trigeminal ganglion. The DRG contains many receptor channels and is an important region for pain signal transduction. Sustained abnormal electrical activity to the spinal cord via the DRG in acute herpes zoster can result in neuropathic conditions such as postherpetic neuralgia (PHN). Although the efficacy of pulsed radiofrequency (PRF) application to the DRG in various pain conditions has been previously reported, the application of PRF to the DRG in patients with herpes zoster has not yet been studied. The aim of the present study was to compare the clinical effects of PRF to the DRG in patients with herpes zoster to those of PRF to the DRG in patients with PHN. Retrospective comparative study. University hospital pain center in Korea. The medical records of 58 patients who underwent PRF to the DRG due to zoster related pain (herpes zoster or PHN) were retrospectively analyzed. Patients were divided into 2 groups according to the timing of PRF after zoster onset: an early PRF group (within 90 days) and a PHN PRF group (more than 90 days). The efficacy of PRF was assessed by a numeric rating scale (NRS) and by recording patient medication doses before PRF and at one week, 4 weeks, 8 weeks, and 12 weeks after PRF. Pain intensity was decreased after PRF in all participants. However, the degree of pain reduction was significantly higher in the early PRF group. Moreover, more patients discontinued their medication in the early PRF group, and the PRF success rate was also higher in the early PRF group. The relatively small sample size from a single center, short duration of review of medical records, and the retrospective nature of the study. PRF to the DRG is a useful treatment for treatment-resistant cases of herpes zoster and PHN. Particularly in herpes zoster patients with intractable pain, application of PRF to the DRG should be considered for pain control and prevention of PHN.Key words: Pulsed radiofrequency, dorsal root ganglion, herpes zoster, postherpetic neuralgia.

Quantification of desoxyrhapontigenin (4-methoxyresveratrol) in rat plasma by LC-MS/MS: Application to pre-clinical pharmacokinetic study.

PubMed

Dai, Yu; Tan, Amanda Li Cheng; Chen, Huan; Ong, Pei Shi; Xiang, Xiaoqiang; Wu, Jinzhu; Lin, Hai-Shu

2018-05-10

Desoxyrhapontigenin (DRG, 4-methoxyresveratrol or trans-3,5-dihydroxy-4'-methoxystilbene) is a naturally occurring resveratrol (RES) derivative with a variety of biological activities. To facilitate its further medicinal exploration, a reliable LC-MS/MS method was developed and validated for the quantification of DRG in rat plasma using heavy isotope labelled RES as an internal standard. The ESI was operated in its negative ion mode while DRG and RES were determined by multiple reaction monitoring (MRM) using precursor-to-product ion transitions of m/z 241.1 → 180.8 and m/z 233.0 → 191.0, respectively. This LC-MS/MS method displayed excellent selectivity, sensitivity (LLOQ = 2.5 ng/ml), accuracy (both intra- and interday mean analytical recovery within 100 ± 15%) and precision (both intra- and interday CV < 15%). The mean matrix factors were all within 1.000 ± 0.150 with CV < 15%. The pharmacokinetic profiles of DRG were subsequently examined in Sprague-Dawley rats. Upon intravenous administration (4 or 10 mg/kg), DRG displayed very rapid clearance (Cl = 338 ± 66 or 275 ± 30 ml/min/kg) and short mean residence time (MRT = 12.9 ± 4.7 or 10.4 ± 0.5 min). After oral administration of DRG fully solubilized by 2-hydroxypropyl-β-cyclodextrin (HP-β-CD), the plasma profiles of DRG were highly erratic with a low absolute bioavailability (F < 9.83 ± 5.31%). When DRG was given at a higher dose (50 mg/kg) in suspension form, the F was increased to 24.1 ± 5.6%. The pharmacokinetic comparison among DRG, RES and some of its hydroxyl analogues stilbenes was performed. The information obtained from this study will facilitate further exploration on DRG as well as other RES derivatives. Copyright © 2018 Elsevier B.V. All rights reserved.

The Danish health care system: it ain't broke... so don't fix it.

PubMed

Mooney, Gavin

2002-02-01

The organisation and financing of the Danish health care system was evaluated within a framework of analysis of strengths, weaknesses, opportunities and threats (a SWOT analysis) by a panel of five members with a background in health economics. The evaluation was based on reading an extensive amount of selected documents and literature on the Danish health care system, and a 1 week-visit to health care authorities, providers and key persons. This paper includes the main findings by one of the panel members. The international competition 'wave' passed by Denmark, and the Danish might rightly say 'thank goodness'. Funding is very largely public and there is a single dominant authority, i.e. the county, which makes planning easier. Low levels of patient payments and the smaller size of the private sector reflect Danish 'solidarity' and promote equity. Planning is good. Exceptions to this are the over-concern with hospital waiting lists and the flirting with DRG based funding. Greater investment in planning approaches would make the system yet better. The GP blended remuneration system with capitation and fee for service is a major strength. The fact that the system has such potential for technical and allocative efficiency and also equity but is not fully exploited suggests the need for more investment in health services research. While there is scope for improving the health care system in Denmark, the rest of the world has as much to learn from the Danes as the Danes have from the rest of the world.

[Variability in nursing workload within Swiss Diagnosis Related Groups].

PubMed

Baumberger, Dieter; Bürgin, Reto; Bartholomeyczik, Sabine

2014-04-01

Nursing care inputs represent one of the major cost components in the Swiss Diagnosis Related Group (DRG) structure. High and low nursing workloads in individual cases are supposed to balance out via the DRG group. Research results indicating possible problems in this area cannot be reliably extrapolated to SwissDRG. An analysis of nursing workload figures with DRG indicators was carried out in order to decide whether there is a need to develop SwissDRG classification criteria that are specific to nursing care. The case groups were determined with SwissDRG 0.1, and nursing workload with LEP Nursing 2. Robust statistical methods were used. The evaluation of classification accuracy was carried out with R2 as the measurement of variance reduction and the coefficient of homogeneity (CH). To ensure reliable conclusions, statistical tests with bootstrapping methods were performed. The sample included 213 groups with a total of 73930 cases from ten hospitals. The DRG classification was seen to have limited explanatory power for variability in nursing workload inputs, both for all cases (R2 = 0.16) and for inliers (R2 = 0.32). Nursing workload homogeneity was statistically significant unsatisfactory (CH < 0.67) in 123 groups, including 24 groups in which it was significant defective (CH < 0.60). Therefore, there is a high risk of high and low nursing workloads not balancing out in these groups, and, as a result, of financial resources being wrongly allocated. The development of nursing-care-specific SwissDRG classification criteria for improved homogeneity and variance reduction is therefore indicated.

Funding issues for Victorian hospitals: the risk-adjusted vision beyond casemix funding.

PubMed

Antioch, K; Walsh, M

2000-01-01

This paper discusses casemix funding issues in Victoria impacting on teaching hospitals. For casemix payments to be acceptable, the average price and cost weights must be set at an appropriate standard. The average price is based on a normative, policy basis rather than benchmarking. The 'averaging principle' inherent in cost weights has resulted in some AN-DRG weights being too low for teaching hospitals that are key State-wide providers of high complexity services such as neurosurgery and trauma. Casemix data have been analysed using international risk adjustment methodologies to successfully negotiate with the Victorian State Government for specified grants for several high complexity AN-DRGs. A risk-adjusted capitation funding model has also been developed for cystic fibrosis patients treated by The Alfred, called an Australian Health Maintenance Organisation (AHMO). This will facilitate the development of similar models by both the Victorian and Federal governments.

42 CFR 412.517 - Revision of LTC-DRG group classifications and weighting factors.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Revision of LTC-DRG group classifications and... classifications and weighting factors. (a) CMS adjusts the classifications and weighting factors annually to... the LTC-DRG classifications and recalibration of the weighting factors described in paragraph (a) of...

42 CFR 412.517 - Revision of LTC-DRG group classifications and weighting factors.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Revision of LTC-DRG group classifications and... classifications and weighting factors. (a) CMS adjusts the classifications and weighting factors annually to... the LTC-DRG classifications and recalibration of the weighting factors described in paragraph (a) of...

Human Nav1.8: enhanced persistent and ramp currents contribute to distinct firing properties of human DRG neurons

PubMed Central

Han, Chongyang; Estacion, Mark; Huang, Jianying; Vasylyev, Dymtro; Zhao, Peng; Dib-Hajj, Sulayman D.

2015-01-01

Although species-specific differences in ion channel properties are well-documented, little has been known about the properties of the human Nav1.8 channel, an important contributor to pain signaling. Here we show, using techniques that include voltage clamp, current clamp, and dynamic clamp in dorsal root ganglion (DRG) neurons, that human Nav1.8 channels display slower inactivation kinetics and produce larger persistent current and ramp current than previously reported in other species. DRG neurons expressing human Nav1.8 channels unexpectedly produce significantly longer-lasting action potentials, including action potentials with half-widths in some cells >10 ms, and increased firing frequency compared with the narrower and usually single action potentials generated by DRG neurons expressing rat Nav1.8 channels. We also show that native human DRG neurons recapitulate these properties of Nav1.8 current and the long-lasting action potentials. Together, our results demonstrate strikingly distinct properties of human Nav1.8, which contribute to the firing properties of human DRG neurons. PMID:25787950

Human Na(v)1.8: enhanced persistent and ramp currents contribute to distinct firing properties of human DRG neurons.

PubMed

Han, Chongyang; Estacion, Mark; Huang, Jianying; Vasylyev, Dymtro; Zhao, Peng; Dib-Hajj, Sulayman D; Waxman, Stephen G

2015-05-01

Although species-specific differences in ion channel properties are well-documented, little has been known about the properties of the human Nav1.8 channel, an important contributor to pain signaling. Here we show, using techniques that include voltage clamp, current clamp, and dynamic clamp in dorsal root ganglion (DRG) neurons, that human Na(v)1.8 channels display slower inactivation kinetics and produce larger persistent current and ramp current than previously reported in other species. DRG neurons expressing human Na(v)1.8 channels unexpectedly produce significantly longer-lasting action potentials, including action potentials with half-widths in some cells >10 ms, and increased firing frequency compared with the narrower and usually single action potentials generated by DRG neurons expressing rat Na(v)1.8 channels. We also show that native human DRG neurons recapitulate these properties of Na(v)1.8 current and the long-lasting action potentials. Together, our results demonstrate strikingly distinct properties of human Na(v)1.8, which contribute to the firing properties of human DRG neurons.

The trauma registry compared to All Patient Refined Diagnosis Groups (APR-DRG).

PubMed

Hackworth, Jodi; Askegard-Giesmann, Johanna; Rouse, Thomas; Benneyworth, Brian

2017-05-01

Literature has shown there are significant differences between administrative databases and clinical registry data. Our objective was to compare the identification of trauma patients using All Patient Refined Diagnosis Related Groups (APR-DRG) as compared to the Trauma Registry and estimate the effects of those discrepancies on utilization. Admitted pediatric patients from 1/2012-12/2013 were abstracted from the trauma registry. The patients were linked to corresponding administrative data using the Pediatric Health Information System database at a single children's hospital. APR-DRGs referencing trauma were used to identify trauma patients. We compared variables related to utilization and diagnosis to determine the level of agreement between the two datasets. There were 1942 trauma registry patients and 980 administrative records identified with trauma-specific APR-DRG during the study period. Forty-two percent (816/1942) of registry records had an associated trauma-specific APR-DRG; 69% of registry patients requiring ICU care had trauma APR-DRGs; 73% of registry patients with head injuries had trauma APR-DRGs. Only 21% of registry patients requiring surgical management had associated trauma APR-DRGs, and 12.5% of simple fractures had associated trauma APR-DRGs. APR-DRGs appeared to only capture a fraction of the entire trauma population and it tends to be the more severely ill patients. As a result, the administrative data was not able to accurately answer hospital or operating room utilization as well as specific information on diagnosis categories regarding trauma patients. APR-DRG administrative data should not be used as the only data source for evaluating the needs of a trauma program. Copyright © 2016 Elsevier Ltd. All rights reserved.

Comprehensive RNA-Seq Expression Analysis of Sensory Ganglia with a Focus on Ion Channels and GPCRs in Trigeminal Ganglia

PubMed Central

Manteniotis, Stavros; Lehmann, Ramona; Flegel, Caroline; Vogel, Felix; Hofreuter, Adrian; Schreiner, Benjamin S. P.; Altmüller, Janine; Becker, Christian; Schöbel, Nicole; Hatt, Hanns; Gisselmann, Günter

2013-01-01

The specific functions of sensory systems depend on the tissue-specific expression of genes that code for molecular sensor proteins that are necessary for stimulus detection and membrane signaling. Using the Next Generation Sequencing technique (RNA-Seq), we analyzed the complete transcriptome of the trigeminal ganglia (TG) and dorsal root ganglia (DRG) of adult mice. Focusing on genes with an expression level higher than 1 FPKM (fragments per kilobase of transcript per million mapped reads), we detected the expression of 12984 genes in the TG and 13195 in the DRG. To analyze the specific gene expression patterns of the peripheral neuronal tissues, we compared their gene expression profiles with that of the liver, brain, olfactory epithelium, and skeletal muscle. The transcriptome data of the TG and DRG were scanned for virtually all known G-protein-coupled receptors (GPCRs) as well as for ion channels. The expression profile was ranked with regard to the level and specificity for the TG. In total, we detected 106 non-olfactory GPCRs and 33 ion channels that had not been previously described as expressed in the TG. To validate the RNA-Seq data, in situ hybridization experiments were performed for several of the newly detected transcripts. To identify differences in expression profiles between the sensory ganglia, the RNA-Seq data of the TG and DRG were compared. Among the differentially expressed genes (> 1 FPKM), 65 and 117 were expressed at least 10-fold higher in the TG and DRG, respectively. Our transcriptome analysis allows a comprehensive overview of all ion channels and G protein-coupled receptors that are expressed in trigeminal ganglia and provides additional approaches for the investigation of trigeminal sensing as well as for the physiological and pathophysiological mechanisms of pain. PMID:24260241

[Clinical and economic analysis of an internal medicine-infectious disease department at a university general hospital (2005-2006)].

PubMed

Gómez, Joaquín; García-Vázquez, Elisa; Antonio Puertas, José; Ródenas, Julio; Herrero, José Antonio; Albaladejo, Carmen; Baños, Víctor; Canteras, Manuel; Alcaraz, Manolo

2009-02-01

Comparative study in patients with infectious diseases admitted to a specialized Internal Medicine-Infectious Diseases Department (IMID) versus those admitted to other medical departments in a university general hospital, investigating quality and cost-effectiveness. Analysis of patients in 10 principle diagnosis-related groups (DRGs) of infectious diseases admitted to the IMID were compared to those admitted to other medical departments (2005-2006). The DRG were divided in 4 main groups: respiratory infections (DGR 88, 89, 90, 540), urinary infections (DRG 320, 321), sepsis (DRG 416, 584), and skin infections (DRG 277, 278). For each group, quality variables (mortality and readmission rate), efficacy variables (mean hospital stay and mean DRG-based cost per patient) and complexity variables (case mix, relative weight, and functional index) were analyzed. 542 patients included in the 10 main infectious disease DRGs were admitted to IMID and 2404 to other medical departments. After adjusting for DRG case mix (case mix 0.99 for IMID and 0.89 for others), mean hospital stay (5.11 days vs. 7.65 days), mortality (3.5% vs. 7.9%) and mean DRG-based economic cost per patient (1521euro/patient vs. 2952euro/patient) was significantly lower in the group of patients hospitalized in IMID than the group in other medical departments (p<0.05). The readmission rate was similar in the 2 groups (5.5% and 6.5%, respectively). The results per each DRG group were similar to the overall results. For a similar case mix, hospitalization in IMID departments had a positive influence on the variables analyzed as compared to hospitalization in other departments, with a shorter mean stay, lower mortality, and lower mean DRG-based economic cost per patient. Creation and development of IMID departments should be an essential objective to improve healthcare quality and respond to social demands.

Use of a Novel High-Resolution Magnetic Resonance Neurography Protocol to Detect Abnormal Dorsal Root Ganglia in Sjögren Patients With Neuropathic Pain

PubMed Central

Birnbaum, Julius; Duncan, Trisha; Owoyemi, Kristie; Wang, Kenneth C.; Carrino, John; Chhabra, Avneesh

2014-01-01

Abstract The diagnosis and treatment of patients with Sjögren syndrome (SS) with neuropathic pain pose several challenges. Patients with SS may experience unorthodox patterns of burning pain not conforming to a traditional “stocking-and-glove” distribution, which can affect the face, torso, and proximal extremities. This distribution of neuropathic pain may reflect mechanisms targeting the proximal-most element of the peripheral nervous system—the dorsal root ganglia (DRG). Skin biopsy can diagnose such a small-fiber neuropathy and is a surrogate marker of DRG neuronal cell loss. However, SS patients have been reported who have similar patterns of proximal neuropathic pain, despite having normal skin biopsy studies. In such cases, DRGs may be targeted by mechanisms not associated with neuronal cell loss. Therefore, alternative approaches are warranted to help characterize abnormal DRGs in SS patients with proximal neuropathic pain. We performed a systematic review of the literature to define the frequency and spectrum of SS peripheral neuropathies, and to better understand the attribution of SS neuropathic pain to peripheral neuropathies. We found that the frequency of SS neuropathic pain exceeded the prevalence of peripheral neuropathies, and that painful peripheral neuropathies occurred less frequently than neuropathies not always associated with pain. We developed a novel magnetic resonance neurography (MRN) protocol to evaluate DRG abnormalities. Ten SS patients with proximal neuropathic pain were evaluated by this MRN protocol, as well as by punch skin biopsies evaluating for intraepidermal nerve fiber density (IENFD) of unmyelinated nerves. Five patients had radiographic evidence of DRG abnormalities. Patients with MRN DRG abnormalities had increased IENFD of unmyelinated nerves compared to patients without MRN DRG abnormalities (30.2 [interquartile range, 4.4] fibers/mm vs. 11.0 [4.1] fibers/mm, respectively; p = 0.03). Two of these 5 SS patients whose neuropathic pain resolved with intravenous immunoglobulin (IVIg) therapy had improvement of MRN DRG abnormalities. We have developed a novel MRN protocol that can detect DRG abnormalities in SS patients with neuropathic pain who do not have markers of peripheral neuropathy. We found that SS patients with MRN DRG abnormalities had statistically significant, increased IENFD on skin biopsy studies, which may suggest a relationship between trophic mediators and neuropathic pain. Given that our literature review has demonstrated that many SS neuropathic pain patients do not have a neuropathy, our findings suggest an important niche for this MRN DRG technique in the evaluation of broader subsets of SS neuropathic pain patients who may not have underlying neuropathies. The improvement of MRN DRG abnormalities in patients with IVIg-induced remission of neuropathic pain suggests that our MRN protocol may be capturing reversible, immune-mediated mechanisms targeting the DRG. PMID:24797167

Role of dorsal root ganglion K2P1.1 in peripheral nerve injury-induced neuropathic pain

PubMed Central

Mao, Qingxiang; Yuan, Jingjing; Xiong, Ming; Wu, Shaogen; Chen, Liyong; Bekker, Alex; Yang, Tiande

2017-01-01

Peripheral nerve injury-caused hyperexcitability and abnormal ectopic discharges in the primary sensory neurons of dorsal root ganglion (DRG) play a key role in neuropathic pain development and maintenance. The two-pore domain background potassium (K2P) channels have been identified as key determinants of the resting membrane potential and neuronal excitability. However, whether K2P channels contribute to neuropathic pain is still elusive. We reported here that K2P1.1, the first identified mammalian K2P channel, was highly expressed in mouse DRG and distributed in small-, medium-, and large-sized DRG neurons. Unilateral lumbar (L) 4 spinal nerve ligation led to a significant and time-dependent reduction of K2P1.1 mRNA and protein in the ipsilateral L4 DRG, but not in the contralateral L4 or ipsilateral L3 DRG. Rescuing this reduction through microinjection of adeno-associated virus-DJ expressing full-length K2P1.1 mRNA into the ipsilateral L4 DRG blocked spinal nerve ligation-induced mechanical, thermal, and cold pain hypersensitivities during the development and maintenance periods. This DRG viral microinjection did not affect acute pain and locomotor function. Our findings suggest that K2P1.1 participates in neuropathic pain development and maintenance and may be a potential target in the management of this disorder. PMID:28326939

Tumor necrosis factor-α-dependent infiltration of macrophages into the dorsal root ganglion in a rat disc herniation model.

PubMed

You, Changcheng; Zhu, Kai; Liu, Xiaoqi; Xi, Chunyang; Zhang, Zhipeng; Xu, Gongping; Yan, Jinglong

2013-11-01

A prospective molecular mechanism of macrophages infiltration in experimental disc herniation. To investigate the mechanisms of macrophages infiltration into the dorsal root ganglion (DRG) in a rat model of disc herniation. Macrophages infiltrate the DRG after application of nucleus pulposus (NP) on the DRG, and may play an important role in radiculopathy. However, the mechanisms of macrophages infiltration after NP application remain poorly understood. After experimental disc herniation in this study, we investigated changes in the expression of ED1 (a marker of macrophages) and vascular cell adhesion molecule-1 (VCAM-1) in DRG using immunofluorescence. We also investigated the expression of ED1 and VCAM-1 in DRG by treatment with tumor necrosis factor-α (TNF-α) inhibitor at the time of surgery. We found a massive ED1-positive macrophages infiltrated the DRG, and VCAM-1-like immunoreactivity vessels became evident after NP application. Furthermore, both macrophage infiltration and VCAM-1 expression were prevented by treatment with TNF-α inhibitor at the time of surgery. These findings indicated that macrophages infiltration into the DRG was TNF-α-dependent, and might be partly mediated by VCAM-1 in the early stage of experimental lumbar disc herination. Taken together, this study provides important preliminary data suggesting that TNF-α plays an important role in the macrophage infiltration. N/A.

Hospital Coding Practice, Data Quality, and DRG-Based Reimbursement under the Thai Universal Coverage Scheme

ERIC Educational Resources Information Center

Pongpirul, Krit

2011-01-01

In the Thai Universal Coverage scheme, hospital providers are paid for their inpatient care using Diagnosis Related Group (DRG) reimbursement. Questionable quality of the submitted DRG codes has been of concern whereas knowledge about hospital coding practice has been lacking. The objectives of this thesis are (1) To explore hospital coding…

[The effect of acupuncture and endogenous c-Fos, c-Jun on regeneration of neuronal dendrite of spared DRG in vitro following partial ganglionectomy].

PubMed

Wang, Te-wei; Wang, Ting-hua; Zhou, Xue; Zhang, Lian-shuang; Xu, Xin-yun

2007-09-01

To explore the effect of acupuncture, endogenous c-Fos and c-Jun on the regeneration of neuronal dendrite of spared dorsal root ganglion (DRG) in vitro following partial ganglionectomy. Five adult male cats were used in this experiment. Their bilateral L1-L5, L7-S2 DRG were removed, and L6 DRG were spared. Then unilaterally, two sets of acupoints (Zusanli(St. 36) and Xuanzhong(G. B. 39); Futu (St. 32) and Sanyinjiao (Sp. 6) located in the distribution area of spinal nerve L6) were electro-stimulated alternately 30 min everyday by electro-needling. Seven days after operation, bilateral L6 DRGs were taken out and were cultured respectively in vitro. Some cultured mediums of the acupuncture lateral wells were totally replaced by each corresponding antibody-cultured medium including respectively 100 ng/mL anti-c-Fos and anti-c-Jun antibody at the 24th hour and terminated after 7 days. The length of the neurite was measured by upside-down light microscopy. Then, cultured cells were stained by the immunohistochemistry ABC method. Data were analyzed by One-way ANOVA and q test. Immunocytochemical staining revealed that over 95% cells were NSE positive cells which were the typical neuron of DRG in vitro. On the 7th day, the average neurite length of the spared DRG group, the anti-c-Fos antibody and the anti-c-Jun antibody group were shorter than that of the acupuncture group (P < 0.05); the average neurite length of the two antibody groups were longer than that of the spared DRG group (P < 0.05). These results indicate that acupuncture, endogenous c-Fos and c-Jun probably promote regeneration of neuronal dendrite of spared DRG in vitro.

Accumulation of methylglyoxal increases the advanced glycation end-product levels in DRG and contributes to lumbar disk herniation-induced persistent pain.

PubMed

Liu, Cui-Cui; Zhang, Xin-Sheng; Ruan, Yu-Ting; Huang, Zhu-Xi; Zhang, Su-Bo; Liu, Meng; Luo, Hai-Jie; Wu, Shao-Ling; Ma, Chao

2017-08-01

Lumbar disk herniation (LDH) with discogenic low back pain and sciatica is a common and complicated musculoskeletal disorder. The underlying mechanisms are poorly understood, and there are no effective therapies for LDH-induced pain. In the present study, we found that the patients who suffered from LDH-induced pain had elevated plasma methylglyoxal (MG) levels. In rats, implantation of autologous nucleus pulposus (NP) to the left lumbar 5 spinal nerve root, which mimicked LDH, induced mechanical allodynia, increased MG level in plasma and dorsal root ganglion (DRG), and enhanced the excitability of small DRG neurons (<30 μm in diameter). Intrathecal injection of MG also induced mechanical allodynia, and its application to DRG neurons ex vivo increased the number of action potentials evoked by depolarizing current pulses. Furthermore, inhibition of MG accumulation by aminoguanidine attenuated the enhanced excitability of small DRG neurons and the mechanical allodynia induced by NP implantation. In addition, NP implantation increased levels of advanced glycation end products (AGEs) in DRG, and intrathecal injection of MG-derived AGEs induced the mechanical allodynia and DRG neuronal hyperactivity. Intrathecal injection of MG also significantly increased the expression of AGEs in DRG. Importantly, scavenging of MG by aminoguanidine also attenuated the increase in AGEs induced by NP implantation. These results suggested that LDH-induced MG accumulation contributed to persistent pain by increasing AGE levels. Thus generation of AGEs from MG may represent a target for treatment of LDH-induced pain. NEW & NOTEWORTHY Our study demonstrates that methylglyoxal accumulation via increasing advanced glycation end-product levels in dorsal root ganglion contributes to the persistent pain induced by lumbar disk herniation, which proposed potential targets for the treatment of lumbar disk herniation-induced persistent pain. Copyright © 2017 the American Physiological Society.

The inhibitory effect of sacral dorsal root ganglion stimulation on nociceptive and nonnociceptive bladder reflexes in cats.

PubMed

Wang, Zhaoxia; Liao, Limin; Deng, Han; Li, Xing; Chen, Guoqing

2018-05-01

To investigate the inhibitory effects of electrical stimulation of sacral dorsal root ganglion (DRG) on bladder activity under non-nociceptive and nociceptive bladder conditions in cats. 12 cats were divided into non-nociceptive and nociceptive groups. Saline was used to distend the bladder and induce non-nociceptive bladder activity, while acetic acid (AA, 0.25%) was used to induce nociceptive bladder overactivity, S1 or S2 DRG stimulation was applied via a pair of hook electrodes placed in the right S1 and S2 DRG. In both non-nociceptive and nociceptive groups, stimulation at 3 and 5 Hz significantly increased bladder capacity (BC) and no significantly different between the two frequencies. In non-nociceptive group, S1 DRG stimulation at 3 Hz was as effective (increasing BC to 139.7 ± 5.6 and 166.9 ± 12.21% of control at 1T and 3/2T, respectively) as S2 DRG stimulation (increases BC to 129.2 ± 5.6 and 160.5 ± 13.3% of control). In nociceptive group, AA reduced the BC to 62.6 ± 11.7% of saline control. S1 DRG stimulation at 3 Hz was also as effective (increasing BC to 54.9 ± 5.5 and 61.9 ± 6.0% of saline control at 1T and 3/2T, respectively) as S2 DRG stimulation (increases BC to 58.3 ± 3.7 and 65.6 ± 3.7% of control). This study showed the effective inhibition on bladder activity under both non-nociceptive and nociceptive conditions, suggesting the possibility of sacral DRG stimulation to treat bladder overactivity.

Intervertebral disc degeneration-induced expression of pain-related molecules: glial cell-derived neurotropic factor as a key factor.

PubMed

Jung, Woon-Won; Kim, Hyun-Sook; Shon, Jong-Ryeul; Lee, Min; Lee, Sang-Heon; Sul, Donggeun; Na, Heung Sik; Kim, Joo Han; Kim, Byung-Jo

2011-10-01

Discogenic low back pain has been shown to develop into chronic intractable pain due to an unknown pathogenesis. To study the mechanism of discogenic pain, we analyzed the serial expression of pain-related molecules in the dorsal root ganglia (DRG) and thalamus using a newly developed rat model of disc degeneration. Ten microliters of complete Freund's adjuvant was injected into the L5-6 disc of male Sprague-Dawley rats for 10 minutes using a 26-gauge needle. Using a behavioral test, rats with significant pain were selected and subsequently serial gene expression of pain-related molecules in the DRG and the thalamus was analyzed by reverse transcriptase polymerase chain reaction. The expression of tumor necrosis factor-α and interleukin-1β significantly increased at 4 and 8 weeks in the DRG of rats with pain. Furthermore, interleukin-6 was significantly increased at 4 weeks in the DRG; however, these cytokines did not show a significant change in the thalamus. Calcitonin gene-related peptide and substance P were significantly increased in DRG at 4 and 8 weeks and in the thalamus at 2 and 4 weeks. The level of nerve growth factor-β did not significantly increase in the DRG or thalamus, whereas glial cell line-derived neurotropic factor (GDNF) was significantly increased at 2 weeks and was sustained through 8 weeks in both the DRG and thalamus. The disc degeneration rat model described herein led to significant pain of a chronic nature. The gradual and persistent increase of GDNF in both the thalamus and DRG suggests that GDNF might be a key factor in the development of intractable, chronic discogenic pain.

Difference of acute dissociation and 1-day culture on the electrophysiological properties of rat dorsal root ganglion neurons.

PubMed

Song, Yuanlong; Zhang, Miaomiao; Tao, Xiaoqing; Xu, Zifen; Zheng, Yunjie; Zhu, Minjie; Zhang, Liangpin; Qiao, Jinhan; Gao, Linlin

2018-01-19

The dissociated dorsal root ganglion (DRG) neurons with or without culture were widely used for investigation of their electrophysiological properties. The culture procedures, however, may alter the properties of these neurons and the effects are not clear. In the present study, we recorded the action potentials (AP) and the voltage-gated Na + , K + , and Ca 2+ currents with patch clamp technique and measured the mRNA of Nav1.6-1.9 and Cav2.1-2.2 with real-time PCR technique from acutely dissociated and 1-day (1-d) cultured DRG neurons. The effects of the nerve growth factor (NGF) on the expression of Nav1.6-1.9 and Cav2.1-2.2 were evaluated. The neurons were classified as small (DRG-S), medium (DRG-M), and large (DRG-L), according to their size frequency distribution pattern. We found 1-d culture increased the AP size but reduced the excitability, and reduced the voltage-gated Na + and Ca 2+ currents and their corresponding mRNA expression in all types of neurons. The lack of NGF in the culture medium may contribute to the reduced Na + and Ca 2+ current, as the application of NGF recovered some of the reduced transcripts (Nav1.9, Cav2.1, and Cav2.2). 1-d culture showed neuron-type specific effects on some of the AP properties: it increased the maximum AP depolarizing rate (MDR) and hyperpolarized the resting membrane potential (RP) in DRG-M and DRG-L neurons, but slowed the maximum AP repolarizing rate (MRR) in DRG-S neurons. In conclusion, the 1-d cultured neurons had different properties with those of the acutely dissociated neurons, and lack of NGF may contribute to some of these differences.

Fixative Composition Alters Distributions of Immunoreactivity for Glutaminase and Two Markers of Nociceptive Neurons, Nav1.8 and TRPV1, in the Rat Dorsal Root Ganglion

PubMed Central

Hoffman, E. Matthew; Schechter, Ruben; Miller, Kenneth E.

2010-01-01

Most, if not all, dorsal root ganglion (DRG) neurons use the neurotransmitter glutamate. There are, however, conflicting reports of the percentages of DRG neurons that express glutaminase (GLS), the enzyme that synthesizes glutamate, ranging from 30% to 100% of DRG neurons. Defining DRG neuron populations by the expression of proteins like GLS, which indicates function, is routinely accomplished with immunolabeling techniques. Proper characterization of DRG neuron populations relies on accurate detection of such antigens. It is known intuitively that fixation can alter immunoreactivity (IR). In this study, we compared the effects of five formaldehyde concentrations between 0.25% and 4.0% (w/v) and five picric acid concentrations between 0.0% and 0.8% (w/v) on the IR of GLS, the voltage-gated sodium channel 1.8 (Nav1.8), and the capsaicin receptor TRPV1. We also compared the effects of five incubation time lengths from 2 to 192 hr, in primary antiserum on IR. Lowering formaldehyde concentration elevated IR for all three antigens, while raising picric acid concentration increased Nav1.8 and TRPV1 IR. Increasing IR improved detection sensitivity, which led to higher percentages of labeled DRG neurons. By selecting fixation conditions that optimized IR, we found that all DRG neurons express GLS, 69% of neurons express Nav1.8, and 77% of neurons express TRPV1, indicating that some previous studies may have underestimated the percentages of DRG neurons expressing these proteins. This manuscript contains online supplemental material at http://www.jhc.org. Please visit this article online to view these materials. (J Histochem Cytochem 58:329–344, 2010) PMID:20026672

Protein kinase A-induced internalization of Slack channels from the neuronal membrane occurs by adaptor protein-2/clathrin-mediated endocytosis.

PubMed

Gururaj, Sushmitha; Evely, Katherine M; Pryce, Kerri D; Li, Jun; Qu, Jun; Bhattacharjee, Arin

2017-11-24

The sodium-activated potassium (K Na ) channel Kcnt1 (Slack) is abundantly expressed in nociceptor (pain-sensing) neurons of the dorsal root ganglion (DRG), where they transmit the large outward conductance I KNa and arbitrate membrane excitability. Slack channel expression at the DRG membrane is necessary for their characteristic firing accommodation during maintained stimulation, and reduced membrane channel density causes hyperexcitability. We have previously shown that in a pro-inflammatory state, a decrease in membrane channel expression leading to reduced Slack-mediated I KNa expression underlies DRG neuronal sensitization. An important component of the inflammatory milieu, PKA internalizes Slack channels from the DRG membrane, reduces I KNa , and produces DRG neuronal hyperexcitability when activated in cultured primary DRG neurons. Here, we show that this PKA-induced retrograde trafficking of Slack channels also occurs in intact spinal cord slices and that it is carried out by adaptor protein-2 (AP-2) via clathrin-mediated endocytosis. We provide mass spectrometric and biochemical evidence of an association of native neuronal AP-2 adaptor proteins with Slack channels, facilitated by a dileucine motif housed in the cytoplasmic Slack C terminus that binds AP-2. By creating a competitive peptide blocker of AP-2-Slack binding, we demonstrated that this interaction is essential for clathrin recruitment to the DRG membrane, Slack channel endocytosis, and DRG neuronal hyperexcitability after PKA activation. Together, these findings uncover AP-2 and clathrin as players in Slack channel regulation. Given the significant role of Slack in nociceptive neuronal excitability, the AP-2 clathrin-mediated endocytosis trafficking mechanism may enable targeting of peripheral and possibly, central neuronal sensitization. © 2017 by The American Society for Biochemistry and Molecular Biology, Inc.

[Decreased A-type potassium current mediates the hyperexcitability of nociceptive neurons in the chronically compressed dorsal root ganglia].

PubMed

Yan, Ni; Li, Xiao-Han; Cheng, Qi; Yan, Jin; Ni, Xin; Sun, Ji-Hu

2007-04-25

The excitability of nociceptive neurons increases in the intact dorsal root ganglion (DRG) after a chronic compression, but the underlying mechanisms are still unclear. The aim of this study was to investigate the ionic mechanisms underlying the hyperexcitability of nociceptive neurons in the compressed ganglion. Chronic compression of DRG (CCD) was produced in adult rats by inserting two rods through the intervertebral foramina to compress the L4 DRG and the ipsilateral L5 DRG. After 5-7 d, DRG somata were dissociated and placed in culture for 12-18 h. In sharp electrode recording model, the lower current threshold and the depolarized membrane potential in the acutely dissociated CCD neurons were detected, indicating that hyperexcitability is intrinsic to the soma. Since voltage-gated K(+) (Kv) channels in the primary sensory neurons are important for the regulation of excitability, we hypothesized that CCD would alter K(+) current properties in the primary sensory neurons. We examined the effects of 4-aminopyridine (4-AP), a specific antagonist of A-type potassium channel, on the excitability of the control DRG neurons. With 4-AP in the external solution, the control DRG neurons depolarized (with discharges in some cells) and their current threshold decreased as the CCD neurons demonstrated, indicating the involvement of decreased A-type potassium current in the hyperexcitability of the injured neurons. Furthermore, the alteration of A-type potassium current in nociceptive neurons in the compressed ganglion was investigated with the whole-cell patch-clamp recording model. CCD significantly decreased A-type potassium current density in nociceptive DRG neurons. These data suggest that a reduction in A-type potassium current contributes, at least in part, to the increase in neuron excitability that may lead to the development of pain and hyperalgesia associated with CCD.

42 CFR 412.540 - Method of payment for preadmission services under the long-term care hospital prospective payment...

Code of Federal Regulations, 2010 CFR

2010-10-01

... the long-term care hospital prospective payment system. 412.540 Section 412.540 Public Health CENTERS... PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care Hospitals... payment system. The prospective payment system includes payment for inpatient operating costs of...

Downregulation of ClC-3 in dorsal root ganglia neurons contributes to mechanical hypersensitivity following peripheral nerve injury.

PubMed

Pang, Rui-Ping; Xie, Man-Xiu; Yang, Jie; Shen, Kai-Feng; Chen, Xi; Su, Ying-Xue; Yang, Chao; Tao, Jing; Liang, Si-Jia; Zhou, Jia-Guo; Zhu, He-Quan; Wei, Xu-Hong; Li, Yong-Yong; Qin, Zhi-Hai; Liu, Xian-Guo

2016-11-01

ClC-3 chloride channel/antiporter has been demonstrated to play an important role in synaptic transmission in central nervous system. However, its expression and function in sensory neurons is poorly understood. In present work, we found that ClC-3 is expressed at high levels in dorsal root ganglia (DRG). Co-immunofluorescent data showed that ClC-3 is mainly distributed in A- and C-type nociceptive neurons. ClC-3 expression in DRG is decreased in the spared nerve injury (SNI) model of neuropathic pain. Knockdown of local ClC-3 in DRG neurons with siRNA increased mechanical sensitivity in naïve rats, while overexpression of ClC-3 reversed the hypersensitivity to mechanical stimuli after peripheral nerve injury. In addition, genetic deletion of ClC-3 enhances mouse mechanical sensitivity but did not affect thermal and cold threshold. Restoration of ClC-3 expression in ClC-3 deficient mice reversed the mechanical sensitivity. Mechanistically, loss of ClC-3 enhanced mechanical sensitivity through increasing the excitability of DRG neurons. These data indicate that ClC-3 is an endogenous inhibitor of neuropathic pain development. Downregulation of ClC-3 by peripheral nerve injury is critical for mechanical hypersensitivity. Our findings suggest that ClC-3 is a novel therapeutic target for treating neuropathic pain. Copyright © 2016 Elsevier Ltd. All rights reserved.

Case-mix tool, costs and effectiveness in improving primary care mental health and substance abuse services.

PubMed

Riihimäki, Kirsi; Heiska-Johansson, Ainomaija; Ketola, Eeva

2018-02-01

Despite its importance in improving care and developing services, high-quality data evaluating cost-effectiveness and services in different case-mix populations is scarce in primary care. The objective was to investigate the service use of those mental health and substance abuse patients, who use lots of services. Primary health care diagnosis-related groups (pDRG) is a tool to evaluate service provider system and improve efficiency, productivity and quality. We viewed all pDRG results available from the year 2015 concerning municipal mental health and substance abuse services. In primary care mental health and substance abuse services, the most common ICD-10-codes were depression and substance abuse. One-fifth of patients produced 57% of costs. Their medium of appointments was 16 per year versus 6 per year of all patients. Only 54% of their diagnoses were recorded in the electronic health records versus 75% of all patients. They made 5.7 different pDRG episodes, including 1.8 episodes of depression, per patient. The average episode cost for this patient group was 301€. pDRG makes health care production transparent also in mental health and substance abuse services. It is easy to identify patients, who use a lot of services and thus induce the majority of costs, and focus on their needs in managing and developing services.

Leukemia inhibitory factor in the neuroimmune communication pathways in allergic asthma.

PubMed

Lin, Min-Juan; Lao, Xue-Jun; Liu, Sheng-Ming; Xu, Zhen-Hua; Zou, Wei-Feng

2014-03-20

In the pathogenesis of asthma, central sensitization is suggested to be an important neural mechanism, and neurotrophins and cytokines are likely to be the major mediators in the neuroimmune communication pathways of asthma. However, their impact on the central nervous system in allergic asthma remains unclear. We hypothesize that central neurogenic inflammation develops in the pathogenesis of allergic asthma, and nerve growth factor (NGF) and leukemia inhibitory factor (LIF) are important mediators in its development. An asthma model of rats was established by sensitization and challenged with ovalbumin (OVA). For further confirmation of the role of LIF in neurogenic inflammation, a subgroup was pretreated with intraperitoneally (i.p.) LIF antibody before OVA challenge. The levels of LIF and NGF were measured with reverse transcription and polymerase chain reaction (RT-PCR), in situ hybridization (ISH) and immunohistochemistry stain in lung tissue, airway-specific dorsal root ganglia (DRG, C7-T5) and brain stem of asthmatic rats, anti-LIF pretreated rats and controls. A significantly increased number of LIF- and NGF-immunoreactive cells were detected in lung tissue, DRG and the brain stem of asthmatic rats. In the asthma group a significantly increase level of mRNA encoding LIF and NGF in lung tissue was detected, but not in DRG and the brain stem. Pretreatment with LIF antibody decreased the level of LIF and NGF in all tissues. LIF is an important mediator in the crosstalk between nerve and immune systems. Our study demonstrate that the increased level of LIF and NGF in DRG and brain stem may be not based on result from de novo synthesis, but rather on result from retrograde nerve transport or passage across the blood-brain-barrier. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Impact of Neuromuscular Electrical Stimulation (NMES) on 90-Day Episode Costs and Post-Acute Care Utilization in Total Knee Replacement Patients with Disuse Atrophy.

PubMed

Pal, Sarmistha; Chughtai, Morad; Sultan, Assem A; Khlopas, Anton; Sodhi, Nipun; George, Nicole E; Etcheson, Jennifer I; Gwam, Chukwuweike U; Newman, Jared M; Samuel, Linsen T; Bhave, Anil; DaVanzo, Joan E; Mont, Michael A

2017-12-22

This study evaluated differences in: 1) total episode payments, 2) probability of hospital readmission, 3) probability of inpatient rehab facility (IRF) and utilization, and 4) probability of skilled nursing care facility (SNF) utilization in patients who had disuse atrophy and underwent a total knee arthroplasty (TKA) and either did, or did not, receive preoperative home-based neuromuscular electrical stimulation (NMES) therapy. We used the Medicare limited dataset for a 5% sample of beneficiaries from 2014 and 2015 to construct episodes-of-care for TKA (DRG-470) patients with disuse atrophy who underwent a TKA during the 30 days prior to hospital admission and 90 days post-discharge. Patients were stratified into those who either did or did not receive pre- and postoperative NMES therapy. An ordinary least square (OLS) model was used to estimate the impact of NMES on total episode. Linear probability models were used to estimate the impact of NMES on SNF or IRF utilization and readmission. A $3,274 reduction in episode payments for patients who used preoperative NMES versus those who did not (p<0.001) was demonstrated. The probability of readmission was 12.7% lower for those who used preoperative NMES therapy versus those who did not (p=0.609). The probability of utilizing IRF and SNF was 56.7% (p=0.061) and 46.4% (p=<0.001) lower for those who used pre- and postoperative NMES versus those who did not, respectively. Significant reduction in total episode payments and SNF utilization for TKA patients with disuse atrophy who had NMES therapy was demonstrated.

42 CFR 476.84 - Changes as a result of DRG validation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Changes as a result of DRG validation. 476.84... § 476.84 Changes as a result of DRG validation. A provider or practitioner may obtain a review by a QIO under part 473 of this chapter for changes in diagnostic and procedural coding that resulted in a change...

42 CFR 476.84 - Changes as a result of DRG validation.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false Changes as a result of DRG validation. 476.84... § 476.84 Changes as a result of DRG validation. A provider or practitioner may obtain a review by a QIO under part 473 of this chapter for changes in diagnostic and procedural coding that resulted in a change...

42 CFR 476.84 - Changes as a result of DRG validation.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false Changes as a result of DRG validation. 476.84... § 476.84 Changes as a result of DRG validation. A provider or practitioner may obtain a review by a QIO under part 473 of this chapter for changes in diagnostic and procedural coding that resulted in a change...

42 CFR 476.84 - Changes as a result of DRG validation.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Changes as a result of DRG validation. 476.84... § 476.84 Changes as a result of DRG validation. A provider or practitioner may obtain a review by a QIO under part 473 of this chapter for changes in diagnostic and procedural coding that resulted in a change...

42 CFR 478.15 - QIO review of changes resulting from DRG validation.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 4 2014-10-01 2014-10-01 false QIO review of changes resulting from DRG validation... review of changes resulting from DRG validation. (a) General rules. (1) A provider or practitioner... validation under section 1866(a)(1)(F) of the Act is entitled to a review of that change if— (i) The change...

42 CFR 478.15 - QIO review of changes resulting from DRG validation.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 4 2013-10-01 2013-10-01 false QIO review of changes resulting from DRG validation... review of changes resulting from DRG validation. (a) General rules. (1) A provider or practitioner... validation under section 1866(a)(1)(F) of the Act is entitled to a review of that change if— (i) The change...

42 CFR 478.15 - QIO review of changes resulting from DRG validation.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false QIO review of changes resulting from DRG validation... review of changes resulting from DRG validation. (a) General rules. (1) A provider or practitioner... validation under section 1866(a)(1)(F) of the Act is entitled to a review of that change if— (i) The change...

42 CFR 478.15 - QIO review of changes resulting from DRG validation.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 4 2012-10-01 2012-10-01 false QIO review of changes resulting from DRG validation... review of changes resulting from DRG validation. (a) General rules. (1) A provider or practitioner... validation under section 1866(a)(1)(F) of the Act is entitled to a review of that change if— (i) The change...

Puerarin blocks the signaling transmission mediated by P2X3 in SG and DRG to relieve myocardial ischemic damage.

PubMed

Liu, Shuangmei; Zhang, Chunping; Shi, Qingming; Li, Guilin; Song, Miaomiao; Gao, Yun; Xu, Changshui; Xu, Hong; Fan, Bo; Yu, Shicheng; Zheng, Chaoran; Zhu, Qicheng; Wu, Bing; Peng, Lichao; Xiong, Huangui; Wu, Qin; Liang, Shangdong

2014-02-01

P2X₃ receptors in stellate ganglia (SG) and cervical dorsal root ganglia (DRG) neurons are involved in sympathoexcitatory reflex induced by myocardial ischemic damage. Puerarin, a major active ingredient extracted from the traditional Chinese plant medicine Ge-gen, has been widely used in treatment of myocardial and cerebral ischemia. The present study is aimed to observe the effects of puerarin on the signaling transmission mediated by P2X₃ receptor in SG and DRG after myocardial ischemic damage. Our results showed that systolic blood pressure and heart rate increased, and the expression levels of P2X₃ mRNA and protein in SG and DRG were up-regulated after myocardial ischemic damage. Puerarin reduced systolic blood pressure and heart rate, relieved pain and decreased up-regulated expression of P2X₃ mRNA and protein in SG and DRG after myocardial ischemia. Puerarin inhibited the up-regulated ATP-activated currents in DRG neurons after myocardial ischemia. Thus, puerarin can relieve myocardial ischemic damage through blocking the P2X₃ signaling transmission and then depressed the aggravated sympathoexcitatory reflex. Copyright © 2014 Elsevier Inc. All rights reserved.

Mouse DRG Cell Line with Properties of Nociceptors.

PubMed

Doran, Ciara; Chetrit, Jonathan; Holley, Matthew C; Grundy, David; Nassar, Mohammed A

2015-01-01

In vitro cell lines from DRG neurons aid drug discovery because they can be used for early stage, high-throughput screens for drugs targeting pain pathways, with minimal dependence on animals. We have established a conditionally immortal DRG cell line from the Immortomouse. Using immunocytochemistry, RT-PCR and calcium microfluorimetry, we demonstrate that the cell line MED17.11 expresses markers of cells committed to the sensory neuron lineage. Within a few hours under differentiating conditions, MED17.11 cells extend processes and following seven days of differentiation, express markers of more mature DRG neurons, such as NaV1.7 and Piezo2. However, at least at this time-point, the nociceptive marker NaV1.8 is not expressed, but the cells respond to compounds known to excite nociceptors, including the TRPV1 agonist capsaicin, the purinergic receptor agonist ATP and the voltage gated sodium channel agonist, veratridine. Robust calcium transients are observed in the presence of the inflammatory mediators bradykinin, histamine and norepinephrine. MED17.11 cells have the potential to replace or reduce the use of primary DRG culture in sensory, pain and developmental research by providing a simple model to study acute nociception, neurite outgrowth and the developmental specification of DRG neurons.

MiR-34a Regulates Axonal Growth of Dorsal Root Ganglia Neurons by Targeting FOXP2 and VAT1 in Postnatal and Adult Mouse.

PubMed

Jia, Longfei; Chopp, Michael; Wang, Lei; Lu, Xuerong; Zhang, Yi; Szalad, Alexandra; Zhang, Zheng Gang

2018-04-10

Hyperglycemia impairs nerve fibers of dorsal root ganglia (DRG) neurons, leading to diabetic peripheral neuropathy (DPN). However, the molecular mechanisms underlying DPN are not fully understood. Using a mouse model of type II diabetes (db/db mouse), we found that microRNA-34a (miR-34a) was over-expressed in DRG, sciatic nerve, and foot pad tissues of db/db mice. In vitro, high glucose significantly upregulated miR-34a in postnatal and adult DRG neurons, which was associated with inhibition of axonal growth. Overexpression and attenuation of miR-34a in postnatal and adult DRG neurons suppressed and promoted, respectively, axonal growth. Bioinformatic analysis suggested that miR-34a putatively targets forkhead box protein P2 (FOXP2) and vesicle amine transport 1 (VAT1), which were decreased in diabetic tissues and in cultured DRG neurons under high glucose conditions. Dual-luciferase assay showed that miR-34a downregulated FOXP2 and VAT1 expression by targeting their 3' UTR. Gain-of- and loss-of-function analysis showed an inverse relation between augmentation of miR-34a and reduction of FOXP2 and VAT1 proteins in postnatal and adult DRG neurons. Knockdown of FOXP2 and VAT1 reduced axonal growth. Together, these findings suggest that miR-34a and its target genes of FOXP2 and VAT1 are involved in DRG neuron damage under hyperglycemia.

76 FR 13292 - Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2011...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-11

... Prospective Payment System and CY 2011 Payment Rates; Changes to the Ambulatory Surgical Center Payment System and CY 2011 Payment Rates; Changes to Payments to Hospitals for Graduate Medical Education Costs..., 2010, entitled ``Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 Payment...

Upregulation of N-type calcium channels in the soma of uninjured dorsal root ganglion neurons contributes to neuropathic pain by increasing neuronal excitability following peripheral nerve injury.

PubMed

Yang, Jie; Xie, Man-Xiu; Hu, Li; Wang, Xiao-Fang; Mai, Jie-Zhen; Li, Yong-Yong; Wu, Ning; Zhang, Cheng; Li, Jin; Pang, Rui-Ping; Liu, Xian-Guo

2018-07-01

N-type voltage-gated calcium (Cav2.2) channels are expressed in the central terminals of dorsal root ganglion (DRG) neurons, and are critical for neurotransmitter release. Cav2.2 channels are also expressed in the soma of DRG neurons, where their function remains largely unknown. Here, we showed that Cav2.2 was upregulated in the soma of uninjured L4 DRG neurons, but downregulated in those of injured L5 DRG neurons following L5 spinal nerve ligation (L5-SNL). Local application of specific Cav2.2 blockers (ω-conotoxin GVIA, 1-100 μM or ZC88, 10-1000 μM) onto L4 and 6 DRGs on the operated side, but not the contralateral side, dose-dependently reversed mechanical allodynia induced by L5-SNL. Patch clamp recordings revealed that both ω-conotoxin GVIA (1 μM) and ZC88 (10 μM) depressed hyperexcitability in L4 but not in L5 DRG neurons of L5-SNL rats. Consistent with this, knockdown of Cav2.2 in L4 DRG neurons with AAV-Cav2.2 shRNA substantially prevented L5-SNL-induced mechanical allodynia and hyperexcitability of L4 DRG neurons. Furthermore, in L5-SNL rats, interleukin-1 beta (IL-1β) and IL-10 were upregulated in L4 DRGs and L5 DRGs, respectively. Intrathecal injection of IL-1β induced mechanical allodynia and Cav2.2 upregulation in bilateral L4-6 DRGs of naïve rats, whereas injection of IL-10 substantially prevented mechanical allodynia and Cav2.2 upregulation in L4 DRGs in L5-SNL rats. Finally, in cultured DRG neurons, Cav2.2 was dose-dependently upregulated by IL-1β and downregulated by IL-10. These data indicate that the upregulation of Cav2.2 in uninjured DRG neurons via IL-1β over-production contributes to neuropathic pain by increasing neuronal excitability following peripheral nerve injury. Copyright © 2018 Elsevier Inc. All rights reserved.

Major trauma: the unseen financial burden to trauma centres, a descriptive multicentre analysis.

PubMed

Curtis, Kate; Lam, Mary; Mitchell, Rebecca; Dickson, Cara; McDonnell, Karon

2014-02-01

This research examines the existing funding model for in-hospital trauma patient episodes in New South Wales (NSW), Australia and identifies factors that cause above-average treatment costs. Accurate information on the treatment costs of injury is needed to guide health-funding strategy and prevent inadvertent underfunding of specialist trauma centres, which treat a high trauma casemix. Admitted trauma patient data provided by 12 trauma centres were linked with financial data for 2008-09. Actual costs incurred by each hospital were compared with state-wide Australian Refined Diagnostic Related Groups (AR-DRG) average costs. Patient episodes where actual cost was higher than AR-DRG cost allocation were examined. There were 16693 patients at a total cost of AU$178.7million. The total costs incurred by trauma centres were $14.7million above the NSW peer-group average cost estimates. There were 10 AR-DRG where the total cost variance was greater than $500000. The AR-DRG with the largest proportion of patients were the upper limb injury categories, many of whom had multiple body regions injured and/or a traumatic brain injury (P<0.001). AR-DRG classifications do not adequately describe the trauma patient episode and are not commensurate with the expense of trauma treatment. A revision of AR-DRG used for trauma is needed. WHAT IS KNOWN ABOUT THIS TOPIC? Severely injured trauma patients often have multiple injuries, in more than one body region and the determination of appropriate AR-DRG can be difficult. Pilot research suggests that the AR-DRG do not accurately represent the care that is required for these patients. WHAT DOES THIS PAPER ADD? This is the first multicentre analysis of treatment costs and coding variance for major trauma in Australia. This research identifies the limitations of the current AR-DRGS and those that are particularly problematic. The value of linking trauma registry and financial data within each trauma centre is demonstrated. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Further work should be conducted between trauma services, clinical coding and finance departments to improve the accuracy of clinical coding, review funding models and ensure that AR-DRG allocation is commensurate with the expense of trauma treatment.

Accumulation of misfolded SOD1 in dorsal root ganglion degenerating proprioceptive sensory neurons of transgenic mice with amyotrophic lateral sclerosis.

PubMed

Sábado, Javier; Casanovas, Anna; Tarabal, Olga; Hereu, Marta; Piedrafita, Lídia; Calderó, Jordi; Esquerda, Josep E

2014-01-01

Amyotrophic lateral sclerosis (ALS) is an adult-onset progressive neurodegenerative disease affecting upper and lower motoneurons (MNs). Although the motor phenotype is a hallmark for ALS, there is increasing evidence that systems other than the efferent MN system can be involved. Mutations of superoxide dismutase 1 (SOD1) gene cause a proportion of familial forms of this disease. Misfolding and aggregation of mutant SOD1 exert neurotoxicity in a noncell autonomous manner, as evidenced in studies using transgenic mouse models. Here, we used the SOD1(G93A) mouse model for ALS to detect, by means of conformational-specific anti-SOD1 antibodies, whether misfolded SOD1-mediated neurotoxicity extended to neuronal types other than MNs. We report that large dorsal root ganglion (DRG) proprioceptive neurons accumulate misfolded SOD1 and suffer a degenerative process involving the inflammatory recruitment of macrophagic cells. Degenerating sensory axons were also detected in association with activated microglial cells in the spinal cord dorsal horn of diseased animals. As large proprioceptive DRG neurons project monosynaptically to ventral horn MNs, we hypothesise that a prion-like mechanism may be responsible for the transsynaptic propagation of SOD1 misfolding from ventral horn MNs to DRG sensory neurons.

[Total hip replacement in the G-DRG-system].

PubMed

Kaufmann, M M; Franz, D; Lassahn, C; Siebert, C H

2007-01-01

Due to the continuing increase in life expectancy, the ageing process of the German population in general and the high demands placed on activity levels and quality of life today, the demand for primary and secondary joint replacement surgery continues to increase. To distribute the economic and medical resources properly, while still making technical and surgical innovations available to a broad public, hospitals must be able to adequately finance these procedures with the help of the proper diagnosis related groups. The development of the German DRG-system over the past years, as well as the new calculation for the year 2006 are to be reviewed and analysed in this article with this in mind. An improvement in the degree of differentiation between the individual procedures can be documented. Whether or not these changes will ensure the long-term financial survival of the German health care system will remain to be seen.

The Different Dynamic Changes of Nerve Growth Factor in the Dorsal Horn and Dorsal Root Ganglion Leads to Hyperalgesia and Allodynia in Diabetic Neuropathic Pain.

PubMed

Gao, Zhifeng; Feng, Yi; Ju, Hui

2017-05-01

Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes and more than half of the patients with DPN have self-reported symptoms referring to painful diabetic neuropathy (PDN). Nerve growth factor (NGF) is a key factor for the nervous system, but the role of it in the neuropathic pain of diabetic patients is unclear. This study aimed to investigate the relationship between the dynamic expression of NGF in dorsal horn and dorsal root ganglion (DRG) of diabetic rats and hyperalgesia and allodynia in diabetic neuropathic pain. It also aimed to explore the effects of exogenous mouse NGF (mNGF) on NGF expression in dorsal horn, DRG, and mechanical pain threshold. Animal research study. Experimental research laboratory. The model of diabetes was established by a single intraperitoneal injection of streptozocin (STZ 55 mg/kg). Firstly, the rats were randomly divided into 2 groups: control group (n = 10) and diabetes group (n = 40). The diabetes group contained 4 subgroups: diabetes week 1 group (DM1, n = 10), diabetes week 2 group (DM2, n = 10), diabetes week 4 group (DM4, n = 10), and diabetes week 8 group (DM8, n = 10). Then, the other rats were randomly divided into 2 groups: control group (n = 10) and treatment group (n = 30). The treatment group contained 3 subgroups: saline group (n = 10), low dose mNGF group (mNGF1, n = 10), and high dose mNGF group (mNGF2, n = 10). Mechanical pain threshold was assessed using Von Frey hairs, before the establishment of the diabetes model and 1, 2, 4, and 8 weeks after the establishment. The NGF expression in dorsal horn and DRG was measured by western blot. The mechanical pain threshold decreased one week after the establishment of the diabetes model, which continued for 8 weeks. The NGF expression in the dorsal horn was reduced 2 weeks after diabetes induction and the decreased NGF expression continued for 4 weeks. However, the NGF expression in DRG was reduced one week after diabetes induction and remained at a low level for 8 weeks. Hyperalgesia occurred when the NGF expression in the DRG decreased and further reduction in the NGF expression in the dorsal horn caused concomitant allodynia. The mechanical pain threshold was significantly elevated 2 weeks after mNGF treatment. The course of diabetes should be much longer and there is not a precise analysis of the quantitative relation between the NGF expression in the dorsal horn/DRG and hyperalgesia/allodynia. In diabetic neuropathic pain, the dynamic changes of the NGF expression in dorsal horn and DRG is involved in the development of hyperalgesia and allodynia respectively. Exogenous mNGF may relieve diabetic neuropathic pain by increasing the NGF expression in dorsal horn and DRG.

[Effect of nitric oxide on the somatic membrane of rat DRG neurons].

PubMed

Cheng, Hong-Ju; Ma, Ke-Tao; Zhao, Lei; Li, Li; Cao, Ying-Ying; Si, Jun-Qiang

2009-11-01

To observe the role of nitric oxide in dorsal root ganglion (DRG) neurons and its related ionic mechanisms, and explore the function of NO in pain transmission process. In freshly isolated rat DRG samples, using intracellular recording technique, we perfused sodium nitroprusside (NO donor) to observe the role of NO in DRG neurons. In 77.45% of the bath cells, application of sodium nitroprusside (10 -100 mmol/L) induced concentration-dependent membrane hyperpolarization (79/102), and remaining neurons had no response. The membrane conductance increased from control value of (21.06 +/- 1.94) nS to (23.08 +/- 0.92) nS during sodium nitroprusside induced hyperpolarization. L-NAME (1 mmol/L), CdCl2 (0.1 mmol/L) and non-sodium BSS failed to change the amplitude of sodium nitroprusside induced hyperpolarization. When BSS containing 10 mmol/L TEA was used, sodium nitroprusside induced hyperpolarization was obviously inhibited. Sodium nitroprusside could cause concentration-dependent hyperpolarization in DRG neurons by activating K+ channels.

DNA methyltransferase DNMT3a contributes to neuropathic pain by repressing Kcna2 in primary afferent neurons

PubMed Central

Zhao, Jian-Yuan; Liang, Lingli; Gu, Xiyao; Li, Zhisong; Wu, Shaogen; Sun, Linlin; Atianjoh, Fidelis E.; Feng, Jian; Mo, Kai; Jia, Shushan; Lutz, Brianna Marie; Bekker, Alex; Nestler, Eric J.; Tao, Yuan-Xiang

2017-01-01

Nerve injury induces changes in gene transcription in dorsal root ganglion (DRG) neurons, which may contribute to nerve injury-induced neuropathic pain. DNA methylation represses gene expression. Here, we report that peripheral nerve injury increases expression of the DNA methyltransferase DNMT3a in the injured DRG neurons via the activation of the transcription factor octamer transcription factor 1. Blocking this increase prevents nerve injury-induced methylation of the voltage-dependent potassium (Kv) channel subunit Kcna2 promoter region and rescues Kcna2 expression in the injured DRG and attenuates neuropathic pain. Conversely, in the absence of nerve injury, mimicking this increase reduces the Kcna2 promoter activity, diminishes Kcna2 expression, decreases Kv current, increases excitability in DRG neurons and leads to spinal cord central sensitization and neuropathic pain symptoms. These findings suggest that DNMT3a may contribute to neuropathic pain by repressing Kcna2 expression in the DRG. PMID:28270689

42 CFR 412.513 - Patient classification system.

Code of Federal Regulations, 2012 CFR

2012-10-01

..., sex, principal diagnosis (that is, the diagnosis established after study to be chiefly responsible for... additional information and decides whether a change in the LTC-DRG assignment is appropriate. If the...

42 CFR 412.513 - Patient classification system.

Code of Federal Regulations, 2014 CFR

2014-10-01

..., sex, principal diagnosis (that is, the diagnosis established after study to be chiefly responsible for... additional information and decides whether a change in the LTC-DRG assignment is appropriate. If the...

Parathyroid hormone-related peptide activates and modulates TRPV1 channel in human DRG neurons.

PubMed

Shepherd, A J; Mickle, A D; McIlvried, L A; Gereau, R W; Mohapatra, D P

2018-05-24

Parathyroid hormone-related peptide (PTHrP) is associated with advanced tumor growth and metastasis, especially in breast, prostate and myeloma cancers that metastasize to bones, resulting in debilitating chronic pain conditions. Our recent studies revealed that the receptor for PTHrP, PTH1R, is expressed in mouse DRG sensory neurons, and its activation leads to flow-activation and modulation of TRPV1 channel function, resulting in peripheral heat and mechanical hypersensitivity. In order to verify the translatability of our findings in rodents to humans, we explored whether this signalling axis operates in primary human DRG sensory neurons. Analysis of gene expression data from recently reported RNA deep sequencing experiments performed on mouse and human DRGs reveals that PTH1R is expressed in DRG and tibial nerve. Furthermore, exposure of cultured human DRG neurons to PTHrP leads to slow-sustained activation of TRPV1 and modulation of capsaicin-induced channel activation. Both activation and modulation of TRPV1 by PTHrP were dependent on PKC activity. Our findings suggest that functional PTHrP/PTH1R-TRPV1 signalling exists in human DRG neurons, which could contribute to local nociceptor excitation in the vicinity of metastatic bone tumor microenvironment. © 2018 European Pain Federation - EFIC®.

An oral form of methylglyoxal-bis-guanylhydrazone reduces monocyte activation and traffic to the dorsal root ganglia in a primate model of HIV-peripheral neuropathy.

PubMed

Lakritz, Jessica R; Yalamanchili, Samshita; Polydefkis, Michael J; Miller, Andrew D; McGrath, Michael S; Williams, Kenneth C; Burdo, Tricia H

2017-08-01

Peripheral neuropathy (PN) is a major comorbidity of HIV infection that is caused in part by chronic immune activation. HIV-PN is associated with infiltration of monocytes/macrophages to the dorsal root ganglia (DRG) causing neuronal loss and formation of Nageotte nodules. Here, we used an oral form of methylglyoxal-bis-guanylhydrazone (MGBG), a polyamine biosynthesis inhibitor, to specifically reduce activation of myeloid cells. MGBG is selectively taken up by monocyte/macrophages in vitro and inhibits HIV p24 expression and DNA viral integration in macrophages. Here, MGBG was administered to nine SIV-infected, CD8-depleted rhesus macaques at 21 days post-infection (dpi). An additional nine SIV-infected, CD8-depleted rhesus macaques were used as untreated controls. Cell traffic to tissues was measured by in vivo BrdU pulse labeling. MGBG treatment significantly diminished DRG histopathology and reduced the number of CD68+ and CD163+ macrophages in DRG tissue. The number of recently trafficked BrdU+ cells in the DRG was significantly reduced with MGBG treatment. Despite diminished DRG pathology, intraepidermal nerve fiber density (IENFD) did not recover after treatment with MGBG. These data suggest that MGBG alleviated DRG pathology and inflammation.

7, 8, 3′-Trihydroxyflavone Promotes Neurite Outgrowth and Protects Against Bupivacaine-Induced Neurotoxicity in Mouse Dorsal Root Ganglion Neurons

PubMed Central

Shi, Haohong; Luo, Xingjing

2016-01-01

Background 7, 8, 3′-trihydroxyflavone (THF) is a novel pro-neuronal small molecule that acts as a TrkB agonist. In this study, we examined the effect of THF on promoting neuronal growth and protecting anesthetics-induced neurotoxicity in dorsal root ganglion (DRG) neurons in vitro. Material/Methods Neonatal mouse DRG neurons were cultured in vitro and treated with various concentrations of THF. The effect of THF on neuronal growth was investigated by neurite outgrowth assay and Western blot. In addition, the protective effects of THF on bupivacaine-induced neurotoxicity were investigated by apoptosis TUNEL assay, neurite outgrowth assay, and Western blot, respectively. Results THF promoted neurite outgrowth of DRG neurons in dose-dependent manner, with an EC50 concentration of 67.4 nM. Western blot analysis showed THF activated TrkB signaling pathway by inducing TrkB phosphorylation. THF also rescued bupivacaine-induced neurotoxicity by reducing apoptosis and protecting neurite retraction in DRG neurons. Furthermore, the protection of THF in bupivacaine-injured neurotoxicity was directly associated with TrkB phosphorylation in a concentration-dependent manner in DRG neurons. Conclusions THF has pro-neuronal effect on DRG neurons by promoting neurite growth and protecting against bupivacaine-induced neurotoxicity, likely through TrkB activation. PMID:27371503

Effect of nerve injury on the number of dorsal root ganglion neurons and autotomy behavior in adult Bax-deficient mice.

PubMed

Lyu, Chuang; Lyu, Gong-Wei; Martinez, Aurora; Shi, Tie-Jun Sten

2017-01-01

The proapoptotic molecule BAX, plays an important role in mitochondrial apoptotic pathway. Dorsal root ganglion (DRG) neurons depend on neurotrophic factors for survival at early developmental stages. Withdrawal of neurotrophic factors will induce apoptosis in DRG neurons, but this type of cell death can be delayed or prevented in neonatal Bax knockout (KO) mice. In adult animals, evidence also shows that DRG neurons are less dependent upon neurotrophic factors for survival. However, little is known about the effect of Bax deletion on the survival of normal and denervated DRG neurons in adult mice. A unilateral sciatic nerve transection was performed in adult Bax KO mice and wild-type (WT) littermates. Stereological method was employed to quantify the number of lumbar-5 DRG neurons 1 month post-surgery. Nerve injury-induced autotomy behavior was also examined on days 1, 3, and 7 post-surgery. There were significantly more neurons in contralateral DRGs of KO mice as compared with WT mice. The number of neurons was reduced in ipsilateral DRGs in both KO and WT mice. No changes in size distributions of DRG neuron profiles were detected before or after nerve injury. Injury-induced autotomy behavior developed much earlier and was more serious in KO mice. Although postnatal death or loss of DRG neurons is partially prevented by Bax deletion, this effect cannot interfere with long-term nerve injury-induced neuronal loss. The exaggerated self-amputation behavior observed in the mutant mice indicates that Bax deficiency may enhance the development of spontaneous pain following nerve injury.

Upregulation of Ryk expression in rat dorsal root ganglia after peripheral nerve injury.

PubMed

Li, Xin; Li, Yao-hua; Yu, Shun; Liu, Yaobo

2008-10-22

To study changes of Ryk expression in dorsal root ganglia (DRG) after peripheral nerve injury, we set up an animal model of unilateral sciatic nerve lesioned rats. Changes of Ryk protein expression in DRG neurons after unilateral sciatic nerve injury were investigated by immunostaining. Changes of Ryk mRNA were also tested by semi-quantitative PCR concurrently. We found, both at the level of protein and mRNA, that Ryk could be induced in cells of ipsilateral DRG after unilateral sciatic nerve lesion. Further investigation by co-immunostaining confirmed that the Ryk-immunoreactive (Ryk-IR) cells were NeuN-immunoreactive (NeuN-IR) neurons of DRG. We also showed the pattern of Ryk induction in DRG neurons after sciatic nerve injury: the number of Ryk IR neurons peaked at 2 weeks post-lesion and decreased gradually by 3 weeks post-lesion. The proportions of different sized Ryk IR neurons were also observed and counted at various stages after nerve lesion. Analysis of Ryk mRNA by RT-PCR showed the same induction pattern as by immunostaining. Ryk mRNA was not expressed in normal or contralateral DRG, but was expressed 1, 2 and 3 weeks post-lesion in the ipsilateral DRG. Ryk mRNA levels increased slightly from 1 to 2 weeks, decreased then by 3 weeks post-lesion. These results indicate that Ryk might be involved in peripheral nerve plasticity after injury. This is a novel function apart from its well-known fundamental activity as a receptor mediating axon guidance and outgrowth.

Postoperative dysesthesia in minimally invasive transforaminal lumbar interbody fusion: a report of five cases.

PubMed

Wang, Honggang; Zhou, Yue; Zhang, Zhengfeng

2016-05-01

Minimally invasive transforaminal lumbar interbody fusion (misTLIF) can potentially lead to dorsal root ganglion (DRG) injury which may cause postoperative dysesthesia (POD). The purpose of retrospective study was to describe the uncommon complication of POD in misTLIF. Between January 2010 and December 2014, 539 patients were treated with misTLIF in investigator group. POD was defined as dysesthetic pain or burning dysesthesia at a proper DRG innervated region, whether spontaneous or evoked. Non-steroidal antiinflammatory drugs, central non-opioid analgesic agent, neuropathic pain drugs and/or intervertebral foramen block were selectively used to treat POD. There were five cases of POD (5/539, 0.9 %), which consisted of one patient in recurrent lumbar disc herniation (1/36, 3 %), one patient in far lateral lumbar disc herniation (1/34, 3 %), and 3 patients in lumbar spondylolisthesis (3/201, 1 %). Two DRG injury cases were confirmed by revision surgery. After the treatment by drugs administration plus DRG block, all patients presented pain relief with duration from 22 to 50 days. A gradual pain moving to distal end of a proper DRG innervated region was found as the beginning of end. Although POD is a unique and rare complication and maybe misdiagnosed as nerve root injury in misTLIF, combination drug therapy and DRG block have an effective result of pain relief. The appearance of a gradual pain moving to distal end of a proper DRG innervated region during recovery may be used as a sign for the good prognosis.

Differential upregulation in DRG neurons of an α2δ-1 splice variant with a lower affinity for gabapentin after peripheral sensory nerve injury

PubMed Central

Lana, Beatrice; Schlick, Bettina; Martin, Stuart; Pratt, Wendy S.; Page, Karen M.; Goncalves, Leonor; Rahman, Wahida; Dickenson, Anthony H.; Bauer, Claudia S.; Dolphin, Annette C.

2014-01-01

The α2δ-1 protein is an auxiliary subunit of voltage-gated calcium channels, critical for neurotransmitter release. It is upregulated in dorsal root ganglion (DRG) neurons following sensory nerve injury, and is also the therapeutic target of the gabapentinoid drugs, which are efficacious in both experimental and human neuropathic pain conditions. α2δ-1 has 3 spliced regions: A, B, and C. A and C are cassette exons, whereas B is introduced via an alternative 3′ splice acceptor site. Here we have examined the presence of α2δ-1 splice variants in DRG neurons, and have found that although the main α2δ-1 splice variant in DRG is the same as that in brain (α2δ-1 ΔA+B+C), there is also another α2δ-1 splice variant (ΔA+BΔC), which is expressed in DRG neurons and is differentially upregulated compared to the main DRG splice variant α2δ-1 ΔA+B+C following spinal nerve ligation. Furthermore, this differential upregulation occurs preferentially in a small nonmyelinated DRG neuron fraction, obtained by density gradient separation. The α2δ-1 ΔA+BΔC splice variant supports CaV2 calcium currents with unaltered properties compared to α2δ-1 ΔA+B+C, but shows a significantly reduced affinity for gabapentin. This variant could therefore play a role in determining the efficacy of gabapentin in neuropathic pain. PMID:24315988

Increase of transcription factor EB (TFEB) and lysosomes in rat DRG neurons and their transportation to the central nerve terminal in dorsal horn after nerve injury.

PubMed

Jung, J; Uesugi, N; Jeong, N Y; Park, B S; Konishi, H; Kiyama, H

2016-01-28

In the spinal dorsal horn (DH), nerve injury activates microglia and induces neuropathic pain. Several studies clarified an involvement of adenosine triphosphate (ATP) in the microglial activation. However, the origin of ATP together with the release mechanism is unclear. Recent in vitro study revealed that an ATP marker, quinacrine, in lysosomes was released from neurite terminal of dorsal root ganglion (DRG) neurons to extracellular space via lysosomal exocytosis. Here, we demonstrate a possibility that the lysosomal ingredient including ATP released from DRG neurons by lysosomal-exocytosis is an additional source of the glial activation in DH after nerve injury. After rat L5 spinal nerve ligation (SNL), mRNA for transcription factor EB (TFEB), a transcription factor controlling lysosomal activation and exocytosis, was induced in the DRG. Simultaneously both lysosomal protein, LAMP1- and vesicular nuclear transporter (VNUT)-positive vesicles were increased in L5 DRG neurons and ipsilateral DH. The quinacrine staining in DH was increased and co-localized with LAMP1 immunoreactivity after nerve injury. In DH, LAMP1-positive vesicles were also co-localized with a peripheral nerve marker, Isolectin B4 (IB4) lectin. Injection of the adenovirus encoding mCherry-LAMP1 into DRG showed that mCherry-positive lysosomes are transported to the central nerve terminal in DH. These findings suggest that activation of lysosome synthesis including ATP packaging in DRG, the central transportation of the lysosome, and subsequent its exocytosis from the central nerve terminal of DRG neurons in response to nerve injury could be a partial mechanism for activation of microglia in DH. This lysosome-mediated microglia activation mechanism may provide another clue to control nociception and pain. Copyright © 2015 IBRO. Published by Elsevier Ltd. All rights reserved.

Upregulation of the sodium channel NaVβ4 subunit and its contributions to mechanical hypersensitivity and neuronal hyperexcitability in a rat model of radicular pain induced by local DRG inflammation

PubMed Central

Xie, Wenrui; Tan, Zhi-Yong; Barbosa, Cindy; Strong, Judith A.; Cummins, Theodore R.; Zhang, Jun-Ming

2016-01-01

High frequency spontaneous firing in myelinated sensory neurons plays a key role in initiating pain behaviors in several different models, including the radicular pain model in which the rat lumbar dorsal root ganglia (DRG) are locally inflamed. The sodium channel isoform NaV1.6 contributes to pain behaviors and spontaneous activity in this model. Among all the isoforms in adult DRG, NaV1.6 is the main carrier of TTX-sensitive resurgent Na currents that allow high-frequency firing. Resurgent currents flow after a depolarization or action potential, as a blocking particle exits the pore. In most neurons the regulatory β4 subunit is potentially the endogenous blocker. We used in vivo siRNA mediated knockdown of NaVβ4 to examine its role in the DRG inflammation model. NaVβ4 but not control siRNA almost completely blocked mechanical hypersensitivity induced by DRG inflammation. Microelectrode recordings in isolated whole DRGs showed that NaVβ4 siRNA blocked the inflammation-induced increase in spontaneous activity of Aβ neurons, and reduced repetitive firing and other measures of excitability. NaVβ4 was preferentially expressed in larger diameter cells; DRG inflammation increased its expression and this was reversed by NaVβ4 siRNA, based on immunohistochemistry and Western blotting. NaVβ4 siRNA also reduced immunohistochemical NaV1.6 expression. Patch clamp recordings of TTX-sensitive Na currents in acutely cultured medium diameter DRG neurons showed that DRG inflammation increased transient and especially resurgent current; effects blocked by NaVβ4 siRNA. NaVβ4 may represent a more specific target for pain conditions that depend on myelinated neurons expressing NaV1.6. PMID:26785322

The Protective Effects of IGF-1 on Different Subpopulations of DRG Neurons with Neurotoxicity Induced by gp120 and Dideoxycytidine In Vitro.

PubMed

Lu, Lin; Dong, Haixia; Liu, Guixiang; Yuan, Bin; Li, Yizhao; Liu, Huaxiang

2014-11-01

Peripheral neuropathy induced by human immunodeficiency virus (HIV) infection and antiretroviral therapy is not only difficult to distinguish in clinical practice, but also difficult to relieve the pain symptoms by analgesics because of the severity of the disease at the later stage. Hence, to explore the mechanisms of HIV-related neuropathy and find new therapeutic options are particularly important for relieving neuropathic pain symptoms of the patients. In the present study, primary cultured embryonic rat dorsal root ganglion (DRG) neurons were used to determine the neurotoxic effects of HIV-gp120 protein and/or antiretroviral drug dideoxycytidine (ddC) and the therapeutic actions of insulin-like growth factor-1 (IGF-1) on gp120- or ddC-induced neurotoxicity. DRG neurons were exposed to gp120 (500 pmol/L), ddC (50 μmol/L), gp120 (500 pmol/L) plus ddC (50 μmol/L), gp120 (500 pmol/L) plus IGF-1 (20 nmol/L), ddC (50 μmol/L) plus IGF-1 (20 nmol/L), gp120 (500 pmol/L) plus ddC (50 μmol/L) plus IGF-1 (20 nmol/L), respectively, for 72 hours. The results showed that gp120 and/or ddC caused neurotoxicity of primary cultured DRG neurons. Interestingly, the severity of neurotoxicity induced by gp120 and ddC was different in different subpopulation of DRG neurons. gp120 mainly affected large diameter DRG neurons (>25 μm), whereas ddC mainly affected small diameter DRG neurons (≤25 μm). IGF-1 could reverse the neurotoxicity induced by gp120 and/or ddC on small, but not large, DRG neurons. These data provide new insights in elucidating the pathogenesis of HIV infection- or antiretroviral therapy-related peripheral neuropathy and facilitating the development of novel treatment strategies.

The Protective Effects of IGF-1 on Different Subpopulations of DRG Neurons with Neurotoxicity Induced by gp120 and Dideoxycytidine In Vitro

PubMed Central

Lu, Lin; Dong, Haixia; Liu, Guixiang; Yuan, Bin; Li, Yizhao; Liu, Huaxiang

2014-01-01

Peripheral neuropathy induced by human immunodeficiency virus (HIV) infection and antiretroviral therapy is not only difficult to distinguish in clinical practice, but also difficult to relieve the pain symptoms by analgesics because of the severity of the disease at the later stage. Hence, to explore the mechanisms of HIV-related neuropathy and find new therapeutic options are particularly important for relieving neuropathic pain symptoms of the patients. In the present study, primary cultured embryonic rat dorsal root ganglion (DRG) neurons were used to determine the neurotoxic effects of HIV-gp120 protein and/or antiretroviral drug dideoxycytidine (ddC) and the therapeutic actions of insulin-like growth factor-1 (IGF-1) on gp120- or ddC-induced neurotoxicity. DRG neurons were exposed to gp120 (500 pmol/L), ddC (50 μmol/L), gp120 (500 pmol/L) plus ddC (50 μmol/L), gp120 (500 pmol/L) plus IGF-1 (20 nmol/L), ddC (50 μmol/L) plus IGF-1 (20 nmol/L), gp120 (500 pmol/L) plus ddC (50 μmol/L) plus IGF-1 (20 nmol/L), respectively, for 72 hours. The results showed that gp120 and/or ddC caused neurotoxicity of primary cultured DRG neurons. Interestingly, the severity of neurotoxicity induced by gp120 and ddC was different in different subpopulation of DRG neurons. gp120 mainly affected large diameter DRG neurons (>25 μm), whereas ddC mainly affected small diameter DRG neurons (≤25 μm). IGF-1 could reverse the neurotoxicity induced by gp120 and/or ddC on small, but not large, DRG neurons. These data provide new insights in elucidating the pathogenesis of HIV infection- or antiretroviral therapy-related peripheral neuropathy and facilitating the development of novel treatment strategies. PMID:25489421

Neuronal Subtype and Satellite Cell Tropism Are Determinants of Varicella-Zoster Virus Virulence in Human Dorsal Root Ganglia Xenografts In Vivo

PubMed Central

Zerboni, Leigh; Arvin, Ann

2015-01-01

Varicella zoster virus (VZV), a human alphaherpesvirus, causes varicella during primary infection. VZV reactivation from neuronal latency may cause herpes zoster, post herpetic neuralgia (PHN) and other neurologic syndromes. To investigate VZV neuropathogenesis, we developed a model using human dorsal root ganglia (DRG) xenografts in immunodeficient (SCID) mice. The SCID DRG model provides an opportunity to examine characteristics of VZV infection that occur in the context of the specialized architecture of DRG, in which nerve cell bodies are ensheathed by satellite glial cells (SGC) which support neuronal homeostasis. We hypothesized that VZV exhibits neuron-subtype specific tropism and that VZV tropism for SGC contributes to VZV-related ganglionopathy. Based on quantitative analyses of viral and cell protein expression in DRG tissue sections, we demonstrated that, whereas DRG neurons had an immature neuronal phenotype prior to implantation, subtype heterogeneity was observed within 20 weeks and SGC retained the capacity to maintain neuronal homeostasis longterm. Profiling VZV protein expression in DRG neurons showed that VZV enters peripherin+ nociceptive and RT97+ mechanoreceptive neurons by both axonal transport and contiguous spread from SGC, but replication in RT97+ neurons is blocked. Restriction occurs even when the SGC surrounding the neuronal cell body were infected and after entry and ORF61 expression, but before IE62 or IE63 protein expression. Notably, although contiguous VZV spread with loss of SGC support would be predicted to affect survival of both nociceptive and mechanoreceptive neurons, RT97+ neurons showed selective loss relative to peripherin+ neurons at later times in DRG infection. Profiling cell factors that were upregulated in VZV-infected DRG indicated that VZV infection induced marked pro-inflammatory responses, as well as proteins of the interferon pathway and neuroprotective responses. These neuropathologic changes observed in sensory ganglia infected with VZV may help to explain the neurologic sequelae often associated with zoster and PHN. PMID:26090802

76 FR 1592 - Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-11

...: Advanced Meat Recovery Systems. OMB Control Number: 0583-0130. Summary of Collection: The Food Safety and... Recovery (AMR) systems ensure that bones used for AMR systems do not contain brain, trigeminal ganglia, or... dorsal root ganglia (DRG); to document their testing protocols, to assess manner that does not cause...

[Effect of different number of bone marrow mesenchymal stem cells on growth of rat dorsal root ganglia in vitro].

PubMed

Xu, Wenjing; Zhao, Zhe; Zhao, Bin; Wang, Yu; Peng, Jiang; Zhang, Li; Chen, Jifeng; Lu, Shibi

2011-10-01

Bone marrow mesenchymal stem cells (BMSCs), as replacement cells of Schwann cells, can increase the effect of peripheral nerve repair. However, it has not yet reached any agreement to add the appropriate number of seeded cells in nerve scaffold. To investigate the effect of different number of BMSCs on the growth of rat dorsal root ganglia (DRG). Three 4-week-old Sprague Dawley (SD) rats (weighing 80-100 g) were selected to isolate BMSCs, which were cultured in vitro. Three 1- to 2-day-old SD rats (weighing 4-6 g) were selected to prepare DRG. BMSCs at passage 3 were used to prepare BMSCs-fibrin glue complex. According to different number of BMSCs at passage 3 in fibrin glue, experiment was divided into group A (1 x 10(3)), group B (1 x 10(4)), group C (1 x 10(5)), and group D (0, blank control), and BMSCs were co-cultured with rat DRG. The axon length of DRG, Schwann cell migration distance, and axon area index were quantitatively evaluated by morphology, neurofilament 200, and Schwann cells S-100 immunofluorescence staining after cultured for 48 hours. Some long cell processes formed in BMSCs at 48 hours; migration of Schwann cells and axons growth from the DRG were observed, growing in every direction. BMSCs in fibrin glue had the biological activity and could effect DRG growth. The axon length of DRG and Schwann cell migration distance in groups A, B, and C were significantly greater than those in group D (P < 0.05). The axon length of DRG and Schwann cell migration distance in group C were significantly less than those in group B (P < 0.05), but there was no significant difference between group A and group C, and between group A and group B (P > 0.05). The axon area index in groups A and B was significantly greater than that in group D (P < 0.05), but there was no significant difference between group C and group D (P > 0.05); there was no significant difference in groups A, B, and C (P > 0.05). In vitro study on DRG culture experiments is an ideal objective neural model of nerve regeneration. The effect of different number of BMSCs in fibrin glue on the growth of DRG has dose-effect relationship. It can provide a theoretical basis for the appropriate choice of the BMSCs number for tissue engineered nerve.

Neto2 Assembles with Kainate Receptors in DRG Neurons during Development and Modulates Neurite Outgrowth in Adult Sensory Neurons

PubMed Central

Vernon, Claire G.

2017-01-01

Peripheral sensory neurons in the dorsal root ganglia (DRG) are the initial transducers of sensory stimuli, including painful stimuli, from the periphery to central sensory and pain-processing centers. Small- to medium-diameter non-peptidergic neurons in the neonatal DRG express functional kainate receptors (KARs), one of three subfamilies of ionotropic glutamate receptors, as well as the putative KAR auxiliary subunit Neuropilin- and tolloid-like 2 (Neto2). Neto2 alters recombinant KAR function markedly but has yet to be confirmed as an auxiliary subunit that assembles with and alters the function of endogenous KARs. KARs in neonatal DRG require the GluK1 subunit as a necessary constituent, but it is unclear to what extent other KAR subunits contribute to the function and proposed roles of KARs in sensory ganglia, which include promotion of neurite outgrowth and modulation of glutamate release at the DRG–dorsal horn synapse. In addition, KARs containing the GluK1 subunit are implicated in modes of persistent but not acute pain signaling. We show here that the Neto2 protein is highly expressed in neonatal DRG and modifies KAR gating in DRG neurons in a developmentally regulated fashion in mice. Although normally at very low levels in adult DRG neurons, Neto2 protein expression can be upregulated via MEK/ERK signaling and after sciatic nerve crush and Neto2−/− neurons from adult mice have stunted neurite outgrowth. These data confirm that Neto2 is a bona fide KAR auxiliary subunit that is an important constituent of KARs early in sensory neuron development and suggest that Neto2 assembly is critical to KAR modulation of DRG neuron process outgrowth. SIGNIFICANCE STATEMENT Pain-transducing peripheral sensory neurons of the dorsal root ganglia (DRG) express kainate receptors (KARs), a subfamily of glutamate receptors that modulate neurite outgrowth and regulate glutamate release at the DRG–dorsal horn synapse. The putative KAR auxiliary subunit Neuropilin- and tolloid-like 2 (Neto2) is also expressed in DRG. We show here that it is a developmentally downregulated but dynamic component of KARs in these neurons, that it contributes to regulated neurite regrowth in adult neurons, and that it is increased in adult mice after nerve injury. Our data confirm Neto2 as a KAR auxiliary subunit and expand our knowledge of the molecular composition of KARs in nociceptive neurons, a key piece in understanding the mechanistic contribution of KAR signaling to pain-processing circuits. PMID:28235897

Hydrophilic/hydrophobic features of TiO2 nanoparticles as a function of crystal phase, surface area and coating, in relation to their potential toxicity in peripheral nervous system.

PubMed

Bolis, V; Busco, C; Ciarletta, M; Distasi, C; Erriquez, J; Fenoglio, I; Livraghi, S; Morel, S

2012-03-01

The hydrophilic/hydrophobic properties of a variety of commercial TiO(2) nanoparticles (NP), to be employed as inorganic filters in sunscreen lotions, were investigated both as such (dry powders) and dispersed in aqueous media. Water uptake and the related interaction energy have been determined by means of adsorption microcalorimetry of H(2)O vapor, whereas dispersion features in aqueous solutions were investigated by dynamic light scattering and electrokinetic measurements (zeta potential). The optimized dispersions in cell culture medium were employed to assess the possible in vitro neuro-toxicological effect on dorsal root ganglion (DRG) cells upon exposure to TiO(2)-NP, as a function of crystal phase, surface area and coating. All investigated materials, with the only exception of the uncoated rutile, were found to induce apoptosis on DRG cells; the inorganic/organic surface coating was found not to protect against the TiO(2)-induced apoptosis. The risk profile for DRG cells, which varies for the uncoated samples in the same sequence as the photo-catalytic activity of the different polymorphs: anatase-rutile>anatase>rutile, was found not to be correlated with the surface hydrophilicity of the uncoated/coated specimens. Aggregates/agglomerates hydrodynamic diameter was comprised in the ~200-400 nm range, compatible with the internalization within DRG cells. Copyright © 2011 Elsevier Inc. All rights reserved.