Nutritional assessment and management in hospitalised patients: Implication for DRG-based reimbursement and health care quality

Introduction: Malnutrition is associated with a higher morbidity resulting in an increased need for medical resources and economic expenses. In order to ensure sufficient nutritional care it is mandatory to identify the effect of malnutrition and nutritional care on direct cost and reimbursement. The primary aim of this study was to evaluate the economic effect of a nutritional screening procedure on the identification and coding of malnutrition in the G-DRG system. Methods: All G-DRG relevant parameters of 541 consecutive patients at a gastroenterology ward were documented. Moreover, all patients were screened for malnutrition by a dietician according to the subjective global assessment (SGA). Patients were then grouped into the appropriate G-DRG and the effective cost weight (CW) was calculated. Results: Ninety-two of 541 patients (19%) were classified malnourished (SGA B or Q. Recognition of malnutrition increase from 4% to 19%. Malnourished patients exhibited a significantly increased length of hospital stay (7.7 +/- 7 to 11 +/- 9, P < 0.0001). In 26/98 (27%) patients, the coding of malnutrition was considered relevant by grouping and resulted in a rise of DRG benefit. Mean case mix value and patients' complexity and comorbidity level (PCCL) increased after including malnutrition in the codification (CV 1.53 +/- 2.9 to 1.65 +/- 2.9, P=0.001 and PCCL 2.69 +/- 1.4 to 3.47 +/- 0.82, P < 0.0001). The reimbursement increase by 360euro/malnourished patient or an additional reimbursement of 35280euro (8.3% of the total reimbursement for all patients of 423186euro). Nutritional support in a subgroup of 50 randomly selected patients resulted in additional costs of 10268euro. Forty-four of these patients (86%) were classified malnourished (32 SGA B and 12 SGA Q. However, the subsequent reimbursement covered only approximately 75% of the expenses (7869euro), but did not include the potential financial benefits resulting from clinical interventions. Conclusion: Malnourished patients can be detected with a structured assessment and documentation of nutritional status and this is partly reflected in the G-DRG/ICD 10 system. In addition to increasing direct health care reimbursement, nutritional screening and intervention has the potential to improve health care quality. (c) 2005 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.