Thus the requirement that the drgs be clinically

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cialties are involved. Thus, the requirement that the DRGs be clinically coherent precludes the possibility of these types of patients being in the same DRG. A common organ system or etiology and a common clinical specialty are necessary but not suffi- cient requirements for a DRG to be clinically coherent. In addition, all available patient characteristics, which medically would be expected to consistently affect resource intensity, should be included in the definition of the DRG. Furthermore, the definition of a DRG should not be based on patient characteristics that medically would not be expected to consistently affect resource intensity. For example, patients with appendicitis may or may not have peritonitis. Although these patients are the same from an organ system, etiology, and medical specialist per- spective, the DRG definitions must form separate patient groups since the presence of peritonitis would be expected to consistently increase the resource intensity of appendicitis patients. On the other hand, sets of unrelated surgical procedures cannot be used to define a DRG since there would not be a medical rationale to substantiate that the resource intensity would be expected to be similar. The definition of clinical coherence is, of course, dependent on the purpose for the formation of the DRG classification. For the DRGs, the definition of clinical coherence relates to the medical rationale for differences in resource intensity. On the other hand, if the purpose of the DRGs related to mortality, the patient characteristics which were clinically coherent and therefore included in the DRG definitions might be different. Finally, it should be noted that the requirement that the DRGs be clinically coherent caused more patient groups to be formed than would be nec- essary for explaining resource intensity alone. Development of the original DRGs The first operational set of DRGs was developed at Yale University in the early 1970s. The pro- cess of forming the original DRGs was begun by dividing all possible principal diagnoses into 23 mutually exclusive principal diagnosis categories referred to as Major Diagnostic Categories (MDCs). The MDCs were formed by physician panels as the first step toward ensuring that the DRGs would be clinically coherent. The diagnoses in each MDC correspond to a single organ system or etiology and in general, are associated with a particular medical specialty. Thus, in order to main- tain the requirement of clinical coherence, no final DRG could contain patients in different MDCs. In general, each MDC was constructed to correspond to a major organ system (e.g., Respiratory System, Circulatory System, Digestive System) rather than etiology (e.g., malignancies, infectious diseases). This approach was used since clinical care is generally organized in accordance with the organ system affected, rather than the etiology. Diseases involving both a particular organ system and a particular etiology (e.g., malignant neoplasm of the kidney) were assigned to the MDC corresponding to the organ system involved. However, not all diseases or disorders could
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  • Fall '18
  • Diagnosis-related group, DRGs

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