James Downie CEO Independent Hospital Pricing Authority

1. Emergency care
costing study
and classification
development
James Downie
Chief Executive Officer
Independent Hospital Pricing Authority

2. Background
www.ihpa.gov.au2

3. Current Emergency care
classifications
• Urgency Related Groups (URG):
‒based on type of visit, triage, episode end status
and diagnosis.
• Urgency Disposition Groups (UDG):
‒based on type of visit, triage and episode end
status.
• Limitations:
‒Both rely on triage (good indicator of urgency,
but not complexity/ resource use).
‒Limited clinical meaning.
3 www.ihpa.gov.au

4. Investigative review of
classification systems for
emergency care
• Commenced mid 2013, completed early 2014.
• Reviewed classifications developed/ used in Australia and
other countries:
‒Extensive clinical consultation.
‒Analysis of existing cost data.
• Conclusions:
‒New classification needed to replace URGs and UDGs.
‒Should be based on a high quality costing study.
‒Diagnosis given more importance and triage less.
‒Better account for patient complexity.
4 www.ihpa.gov.au

5. Emergency
care costing &
classification
project
www.ihpa.gov.au5

6. Development of a new
classification system for
emergency care
• Commenced mid 2015.
• Engaged consortium led by Health Policy Analysis.
• Key objectives:
‒Undertake a detailed costing study to investigate costs
associated with emergency care.
‒Develop a new patient-based classification system for
emergency care.
‒Modifications and enhancements to emergency care
data collections required to support the new
classification.
6 www.ihpa.gov.au

7. Costing Study Overview
• Inform classification development.
• Strong focus on consultation and clinically driven.
• All data provided to IHPA was de-identified and handled
in accordance with strict data governance processes.
• Ethics approval from the South Australian Human
Research Ethics Committee, and states/ territories also
obtained their own approvals.
• All sites in the study used barcode scanning technology
to record clinicians’ time spent with patients and the
activity/ procedure undertaken.
7 www.ihpa.gov.au

8. Costing Study Overview
• 10 sites from NSW, WA, SA, NT - included specialist
paediatric, major city and regional/remote hospitals.
• One month data collection between April to June 2016:
‒Two-week intensive collection of clinician time.
‒Investigations, procedures, presenting problem, and
other patient characteristics that impact on complexity
(termed ‘diagnosis modifiers’) were collected for the
whole four week period.
• Sites also submitted routinely collected data for the
remainder of the 2015-16 financial year.
8 www.ihpa.gov.au

9. Consensus study
of clinician time
• Undertaken in addition to the costing study data
collection.
• Aimed to estimate times for procedures and other
patient-related activities undertaken by ED clinicians.
• Estimates provided by approximately 300 clinicians
through Delphi process (medical, nursing, allied
health).
• Validate the results from the costing study and
potentially supplement data that might be missing for
specific procedures/ activities for any hospital.
9 www.ihpa.gov.au

10. Costing of data
• Activity data costed using project specific relative value
units (RVUs) based on clinician time data collected.
• Aligned with the Costing Standards/ NHCDC processes.
• Project specific working group established to ensure
consistency of costing was applied across sites.
• Validation processes to compare results from study with
standard processes to assess improvements.
• Further work to assess feasibility to implement outcomes
into future routine costing processes.
10 www.ihpa.gov.au

11. Costing study results
• Total of 43,175 presentations were captured during the
four week period; 21,765 of these attributed to two week
clinician time period.
• 83% of the presentations in two week clinician time
period had at least one procedure recorded;
approximately 8.4 procedures per ED patient stay.
• Overall mean cost per ED presentation for the study
period was $696 (median cost of $578).
• Components of overall direct costs included: medical
(26%), nursing (24%), imaging (11%), pathology (8%).
11 www.ihpa.gov.au

12. Cost distribution.
12 www.ihpa.gov.au

13. Distribution of costs by
hospital
13 www.ihpa.gov.au

14. Costing study results
• Data demonstrated several variables collected are
correlated with higher costs:
‒more urgent triage categories
‒increasing age
‒patients that were admitted, referred to another
hospital or died in ED
‒indigenous status
‒confusion/agitation, unconsciousness, mental health
status.
14 www.ihpa.gov.au

15. Triage is a cost driver
15 www.ihpa.gov.au

16. Age drives cost
16 www.ihpa.gov.au

17. Costing study results
• Four most commonly reported categories for ED
principal diagnosis: injuries (23% of total sample),
respiratory system disorders (11%), digestive system
disorders (11%) and circulatory system disorders (10%).
• Most common presenting problems included: abdominal
pain, chest pain, other specified problem, pain lower
limb/hip, review/medical assessment requested.
• Hospital level effects (e.g. role level/ specialisation and
location factors) impact on costs.
17 www.ihpa.gov.au

18. Costing study results – cont.
Cost by presence of diagnosis modifiers
18 www.ihpa.gov.au

19. Costing study results – cont.
Cost by episode end status category
19 www.ihpa.gov.au

20. Classification
development
www.ihpa.gov.au20

21. Proposed classification
structure
21 www.ihpa.gov.au

22. Classification development
timeframes
• Classification development initial data analysis and data
development (Jun – Sept 2017).
• Consultation on the new classification and data
development recommendations (Sept – Dec 2017).
‒Public consultation period (Oct – Nov 2017).
• Finalisation of classification system, supporting
components and final report (early 2018).
• Implementation from 1 July 2019.
22 www.ihpa.gov.au

23. Further information
• IHPA website:
https://www.ihpa.gov.au/what-we-do/emergency-care
• Study website:
http://www.edclassificationstudy.com
• Email:
enquiries.ihpa@health.gov.au
23 www.ihpa.gov.au

24. 24 www.ihpa.gov.au