Project

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Assessing the impact of Diagnosis Related Groups (DRGs) on patient care and professional practice: an interdisciplinary approach

Applicant Biller-Andorno Nikola
Number 132786
Funding scheme Sinergia
Research institution Institut für Biomedizinische Ethik und Medizingeschichte Ethik-Zentrum der Universität Zürich
Institution of higher education University of Zurich - ZH
Main discipline Public Health and Health Services
Start/End 01.01.2011 - 31.12.2013
Approved amount 999'066.93
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Keywords (13)

Diagnosis Related Groups (DRGs); prospective payment system; conflicts of interest; indicators; hospital reimbursement; medical ethics; law; nursing science; health care services research; quality management; patient-centered care; professional practice; cost-containment in health care

Lay Summary (English)

Lead
Lay summary
Aims of the projectTo develop indicators and instruments that can help assess the impact of DRGs on patient care and professional practice. BackgroundDiagnosis Related Groups (DRGs) will be introduced in Swiss hospitals by 2012, based on a revision of the Swiss Health Insurance Law (KVG) in 2007. The new reimbursement system sets an incentive for health care professionals to concentrate on the main diagnosis of a patient and to discharge patients in an efficient manner. DRGs were developed in the USA in the 1960s and have subsequently been implemented in various countries. Several Swiss cantons have used DRGs for a number of years already.The implementation of cost-containment structures like DRGs has been controversial. A discussion on how to ethically allocate scarce health care resources has been ongoing for decades. There is an evolving consensus that resources are limited and their well-considered use is morally required. However, physicians or nurses working in structures that set incentives for cost-containment may perceive a conflict of interest: wanting to provide the best possible care to their patient on the one hand and wanting to be loyal to their institution and its economic viability on the other. Compromised quality of patient care, less equitable access to health care services, shifting delivery of health care to inadequately prepared institutions, and decreasing job satisfaction among health care workers are being projected if DRGs are being implemented.Despite its unquestioned importance, up to now no country has developed comprehensive evaluation and monitoring tools that address medically, ethically and legally relevant aspects. The project will take up this gap. The research group brings together expertise in the areas of medical ethics, law, nursing science, health services research and - through consulting experts - health economics, policy-making and management. MethodologyThe project focuses on three themes: 1) quality of health care, 2) access to health care and 3) job satisfaction of nurses and physicians (including perceived autonomy at work and compatibility of working conditions with health care worker's codes of ethics). The five subprojects (Medical Ethics, Law, Nursing Science, Health Services Research I and II) will use different methodological tools, such as qualitative interviews, quantitative surveys, analysis of health care monitoring instruments. The project will be coordinated by the Institute of Biomedical Ethics, University of Zurich. Regular meetings will be organized in order to achieve the best cooperation and synergies possible between the subgroups, external experts and stakeholders.
Direct link to Lay Summary Last update: 21.02.2013

Responsible applicant and co-applicants

Employees

Publications

Publication
365 Tage SwissDRG: Anreize, Instrumente, Wirkungen
Leu Agnes, Gächter Thomas, Elger Bernice (2013), 365 Tage SwissDRG: Anreize, Instrumente, Wirkungen, in Hill: Zeitschrift für Recht und Gesundheit, (95), 1.
Cost containment methods for hospital reimbursement in China and ethical tensions
Jin Pingyue, Biller-Andorno Nikola, Wild Verina (2013), Cost containment methods for hospital reimbursement in China and ethical tensions, in Asian Bioethics Review, 5(2), 1.
Erste Resultate aus der DRG-Begleitforschung Pflege: Das Motto für die Pflege unter DRG: Risiken erkennen – rechtzeitig handeln
Staudacher Diana, Kleinknecht Michael, Spirig Rebecca (2013), Erste Resultate aus der DRG-Begleitforschung Pflege: Das Motto für die Pflege unter DRG: Risiken erkennen – rechtzeitig handeln, in Competence, 4, 24-25.
Moral Distress and Moral Conflict in Clinical Ethics
Fourie Carina (2013), Moral Distress and Moral Conflict in Clinical Ethics, in Bioethics, 1.
Erste Pilotergebnisse Moralischer Stress
Kleinknecht Michael, Haubner Sandra, Staudacher Diana, Spirig Rebecca (2012), Erste Pilotergebnisse Moralischer Stress, in Care Management, 5(1), 16-19.
Ethical research on the implementation of DRGs in Switzerland - a challenging project
Wild Verina, Pfister Eliane, Biller-Andorno Nikola (2012), Ethical research on the implementation of DRGs in Switzerland - a challenging project, in Swiss Medical Weekly 2012, 142, 1-6.
Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review
Januel JM, Guanmin C, Ruffieux C, Quan H, Douketis JD, Crowther MA, Colin C, Ghali WA, Burnand B (2012), Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review, in JAMA, 307(3), 294-303.
Arbeiten unter DRG-Bedingungen: Erfahrungen aus deutschen Krankenhäusern
Wild Verina (2011), Arbeiten unter DRG-Bedingungen: Erfahrungen aus deutschen Krankenhäusern, in Pfister Eliane, Wild Verina, Biller-Andorno Nikola (ed.), 35-40.
Daten vor und nach der DRG-Einführung
Kleinknecht Michael, Frei Irena Anna, Spichiger Elisabeth, Müller Marianne, Martin Jacqueline S, Staudacher Diane, Spirig Rebecca (2011), Daten vor und nach der DRG-Einführung, in Krankenpflege , 16-18.
Diagnose Fallpauschale
Clarinval Caroline, Pfister Eliane, Biller-Andorno Nikola (2011), Diagnose Fallpauschale, in pipette, 16-17.
DRG - Eine Chance für Spitäler
Kleinknecht Michael, Frei Irena Anna, Staudacher Diana, Spichiger Elisabeth, Martin Jacqueline S., Spirig Rebecca (2011), DRG - Eine Chance für Spitäler, in Schweizerische Ärztezeitung, 2011, 379-381.
DRG & Ethik: Ethische Auswirkungen von ökonomischen Steuerungselementen im Gesundheitswesen
Pfister Eliane, Wild Verina, Biller-Andorno Nikola (ed.) (2011), DRG & Ethik: Ethische Auswirkungen von ökonomischen Steuerungselementen im Gesundheitswesen.
DRGs: Wohlfühlfaktor Begleitforschung?
Biller-Andorno Nikola, Pfister Eliane, Wild Verina (2011), DRGs: Wohlfühlfaktor Begleitforschung?, in PSY & PSY Bulletin, 1(11), 4-5.
Empirische Untersuchungen zu DRG und Managed Care in den USA
Bastami Sohaila, Wild Verina (2011), Empirische Untersuchungen zu DRG und Managed Care in den USA, in Biller-Andorno Nikola, Pfister Eliane, Wild Verina (ed.), 47-61.
Fokusgruppen-Gespräche zu DRG: Befürchtungen und Hoffnungen
Spirig R, Staudacher D, Rettke H, Kleinknecht M (2011), Fokusgruppen-Gespräche zu DRG: Befürchtungen und Hoffnungen, in Krankenpflege. Soins Infirmiers, 2, 18-19.
Ökonomische Steuerungselemente im Gesundheitswesen. Welche Rolle spielt die Ethik?
Wild Verina, Pfister Eliane, Biller-Andorno Nikola (2011), Ökonomische Steuerungselemente im Gesundheitswesen. Welche Rolle spielt die Ethik?, in Pfister Eliane, Wild Verina, Biller-Andorno Nikola (ed.), 207-213.
Wie können DRG die Pflege an Schweizer Spitälern beeinflussen?
Spirig Rebecca, Staudacher Diana, Rettke Horst, Kleinknecht Michael (2011), Wie können DRG die Pflege an Schweizer Spitälern beeinflussen?, in Pfister Eliane, Biller-Andorno Nikola, Wild Verina (ed.), 17-24.
Ethical implications of case-based payment in China: A systematic analysis
Jin Pingyue, Biller-Andorno Nikola, Wild Verina, Ethical implications of case-based payment in China: A systematic analysis, in Developing World Bioethics, 1.
Systematically Evaluating the Impact of Diagnosis-Related Groups (DRGs) on Health Care Delivery: A Matrix of Ethical Implications
Fourie Carina, Biller-Andorno Nikola, Wild Verina, Systematically Evaluating the Impact of Diagnosis-Related Groups (DRGs) on Health Care Delivery: A Matrix of Ethical Implications, in Health Policy, 1.

Collaboration

Group / person Country
Types of collaboration
Institute for Public Health, Department of Community Health Sciences, University of Calgary Canada (North America)
- in-depth/constructive exchanges on approaches, methods or results
High Authority of Health (HAS), Paris France (Europe)
- in-depth/constructive exchanges on approaches, methods or results
Canadian Institute for Health Information (CIHI), Toronto Canada (North America)
- in-depth/constructive exchanges on approaches, methods or results
Department of Medical Information, Health Evaluation and Clinical Research, Hospices Civils of Lyon France (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Research Infrastructure
Center for health policy and management, Chinese Academy of Medical Sciences China (Asia)
- Publication
- Research Infrastructure
School of Health, Care and Social Welfare, Mälardalen University Sweden (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
School of Nursing, Faculty of Medicine, McGill University Montreal Canada (North America)
- in-depth/constructive exchanges on approaches, methods or results
- Publication

Scientific events

Active participation

Title Type of contribution Title of article or contribution Date Place Persons involved
Kolloquium zur Medizin- und Wissenschaftsgeschichte Talk given at a conference 02.12.2013 Giessen, Germany Wild Verina;
28. Jahrestagung der Schweizerischen Gesellschaft für Mund-, Kiefer- und Gesichtschirurgie in Basel: Der MKG-Chirurg unter dem Einfluss von Ökonomisierung, Politik und Ethik Talk given at a conference 22.11.2013 Basel, Switzerland Wild Verina;
UNESCO Chair in Bioethics 9th World Conference Talk given at a conference 19.11.2013 Naples, Italy Fourie Carina; Wild Verina;
4. Notfallpflege-Kongress 2013 Talk given at a conference 07.11.2013 Interlaken, Switzerland Spirig Rebecca;
European Nurse Directors' Association (ENDA) Kongress 2013 Talk given at a conference 31.10.2013 Zurich, Switzerland Spirig Rebecca;
Jahrestagung der Akademie für Ethik in der Medizin Talk given at a conference 10.10.2013 München, Germany Wild Verina; Fourie Carina;
XXIIème Congrès de l'ALASS Talk given at a conference 01.09.2013 Lausanne, Switzerland Vader John-Paul; Januel Jean-Marie; Burnand Bernard;
St. Galler Tagung zum Gesundheitsrecht (3) Talk given at a conference 22.08.2013 Zurich, Switzerland Elger Bernice; Gächter Thomas; Leu Agnes;
Harvard Bioethics Course Individual talk 12.06.2013 Boston, Harvard, United States of America Biller-Andorno Nikola;
Institute for Public Health, University of Calgary Individual talk 06.06.2013 Calgary, Canada Januel Jean-Marie;
Center for Healthcare Policy and Research, CHPR Seminar Series. UC Davis Health System Individual talk 09.05.2013 Sacramento, United States of America Januel Jean-Marie;
CHS/IPH Seminar, Department of Community Health Sciences and the Institute for Public Health, University of Calgary Individual talk 19.04.2013 Calgary, Canada Januel Jean-Marie;
Harvard School of Public Health HPM Research Seminar Individual talk 10.12.2012 Boston, Harvard, United States of America Biller-Andorno Nikola;
The International Society for Quality in Health Care (ISQua) 29th International Conference Talk given at a conference 21.10.2012 Geneva, Switzerland Burnand Bernard; Januel Jean-Marie;
11th World Congress of Bioethics Poster 26.06.2012 Rotterdam, Netherlands Biller-Andorno Nikola; Clarinval Caroline Francoise; Wild Verina;
11th World Congress of Bioethics Poster 26.06.2012 Rotterdam, Netherlands Biller-Andorno Nikola; Wild Verina;
Annual Meeting of the WHO-FIC (Family of International Classifications) Network Poster 29.10.2011 Cape Town, South Africa Burnand Bernard; Januel Jean-Marie; Vader John-Paul;
25th Conference of the European Society for Philosophy of Medicine and Health Care Talk given at a conference 17.08.2011 Zürich, Switzerland Wild Verina;


Self-organised

Title Date Place
IDoC Workshop taking stock of the current research status 07.12.2012 Institute of Biomedical Ethics, University of Zurich, Switzerland
IDoC Workshop on research on DRGs 11.05.2012 University of Zurich, Switzerland
Economy Workshop 25.11.2011 Zürich, Switzerland
Methodology Workshop 10.06.2011 Zürich, Switzerland
DRG Kick-off meeting 03.02.2011 Zürich, Switzerland

Knowledge transfer events

Active participation

Title Type of contribution Date Place Persons involved
4. Notfallpflege-Kongress 2013 07.11.2013 Interlaken, Switzerland Spirig Rebecca;
ENDA Kongress 2013 (European Nursing Directors' Association) 31.10.2013 Zurich, Switzerland Spirig Rebecca;
“Ökonomisierung der Medizin aus der Sicht der Medizinethik”. Public presentation on invitation by the ethics committee 30.06.2013 Ulm, Germany Wild Verina;
SBK-Kongress 2013 (Schweizer Berufsverband der Pflegefachfrauen und Pflegefachmänner) 30.05.2013 St Galen, Switzerland Spirig Rebecca;
DRGs im Krankenhausalltag: Welchen Spielraum hat die Medizinethik? 26.04.2013 Greifswald, Germany Wild Verina;
Trendtage Luzern 13.02.2013 Luzern, Switzerland Spirig Rebecca;
Jahrestagung der Vereinigung der Schweizerischen Stomatherapeutinnen 08.11.2012 Nottwil, Switzerland Spirig Rebecca;
Swiss Public Health Conference 2012 30.08.2012 CHUV Lausanne, Switzerland Vader John-Paul; Wild Verina; Burnand Bernard; Biller-Andorno Nikola; Clarinval Caroline Francoise;
2nd Congresso Infermieristico EOC 09.05.2012 Lugano, Switzerland Spirig Rebecca;
DRGs und Veränderungen in der Gesundheitsversorgung: Eine Analyse ethischer Fragen und deren Wahrnehmung durch Ärztinnen und Ärzte 24.04.2012 Affoltern a.A., Switzerland Biller-Andorno Nikola;
Versorgungsqualität unter SwissDRG – Pflege im Brennpunkt 16.11.2011 Aarau, Switzerland Spirig Rebecca;


Self-organised

Title Date Place
Conference: DRG Begleitforschung Pflege: Erste Resultate 23.11.2012 University Hospital Zurich, Switzerland

Communication with the public

Communication Title Media Place Year
Media relations: radio, television Ökonomisierung der Medizin: Flucht vor dem System Fallpauschale DRS 2 (SRF) German-speaking Switzerland 2012
Media relations: print media, online media Studie soll zeigen, wie sich die Pflege unter DRG entwickelt USZ Press Release German-speaking Switzerland 2012
Media relations: print media, online media DRG – wird die Pauschale zur Falle? UZH News German-speaking Switzerland 2011
Media relations: print media, online media Wir wollen die Wirklichkeit darstellen Schweizerische Ärztezeitung German-speaking Switzerland 2011

Associated projects

Number Title Start Funding scheme
156274 Inpatient-outpatient transitions in the era of DRGs: the legal framework and current practice 01.11.2015 Interdisciplinary projects
139234 Public Health Ethics: From Theory to Practice. International Short Visit at Mailman School of Public Health, Columbia University, New York 01.08.2011 International short research visits

Abstract

As stipulated by the partial revision of the Federal Law on Health Insurance, Diagnosis Related Groups (DRGs) will be introduced as a prospective reimbursement system in Swiss in-patient hospital care by 2012, replacing the previous fee-for-service arrangements. This decision has caused considerable controversy among the different stakeholders, due to the diverging appraisals of what will happen when DRGs are introduced as economic management tools on a national scale. On the positive side, DRGs are expected to promote transparency and efficiency while helping to contain health care costs. On the negative side, compromised quality of patient care, less equitable access to health care services, shifting delivery of health care to inadequately prepared institutions such as nursing homes, and decreasing job satisfaction among nurses and physicians are being projected. Although the introduction of DRGs is supposed to be accompanied by an assessment of its economic effects and its consequences for health care quality, it is quite obvious that a narrow focus on cost efficiency and patient safety will not suffice to fully evaluate the concerns raised by the skeptical voices.To develop more comprehensive evaluation and monitoring tools that can address a spectrum of ethical and legal concerns about DRGs is a complex task that requires input from various disciplines. The research group assembled in the context of this proposal is uniquely positioned to carry out this task. It brings together expertise in the areas of medical ethics, law, nursing science, health services research and - through its network of consulting experts - health economics, policy-making and management. Ongoing pilot projects conducted by members of the group have already produced valuable insights and have identified relevant stakeholders (representing physicians, nurses, patients, hospital administrations, health insurers, the Swiss DRG cooperation, government officials and politicians). This will allow the project to proceed swiftly in the development of qualitative and quantitative tools as well as in the organization of workshops that will further methodological and normative discussions.The project will focus on three themes: 1) quality of health care (understood in a more comprehensive sense, including patient satisfaction), 2) access to health care and 3) job satisfaction of nurses and physicians (including parameters such as perceived autonomy at work and the compatibility of working conditions with health care worker’s individual or professional codes of ethics). It will provide empirical data on selected quality indicators as well as data on the perspectives of physicians, nurses and hospital administrators on the introduction of DRGs. These data will be compared to expectations raised in the literature and in expert and stakeholder interviews. The timing of the project (from fall 2010 through fall 2013) is ideal for this purpose, as it will allow baseline data to be gathered before the nationwide introduction of DRGs, while drawing on previous experiences with DRGs in Germany as well as in some Swiss cantons. It will also cover the early implementation phase of the DRG system, which can help identify potential causal factors triggering certain changes (e.g. shortened duration of hospital stays). Beyond the empirical data, the project will provide a critical analysis of the ethical and legal issues involved, and will provide a set of instruments, together with recommendations for future evaluation and monitoring. The methodological knowledge regarding the challenges and limits of assessing the impact of DRGs can also inform the assessment of other future health policy changes. Finally, the project expects to provide impulses for larger normative discussions on themes such as the tension between fair access to high quality health care, professional autonomy and cost-efficiency.
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