The importance of comorbidity in analysing patient costs in Swedish primary care

Abstract

BackgroundThe objective was to explore the usefulness of the morbidity risk adjustment system Adjusted Clinical Groups® (ACG), in comparison with age and gender, in explaining and estimating patient costs on an individual level in Swedish primary health care. Data were retrieved from two primary health care centres in southeastern Sweden.MethodsA cross-sectional observational study. Data from electronic patient registers from the two centres were retrieved for 2001 and 2002, and patients were grouped into ACGs, expressing the individual combination of diagnoses and thus the comorbidity. Costs per patient were calculated for both years in both centres. Cost data from one centre were used to create ACG weights. These weights were then applied to patients at the other centre. Correlations between individual patient costs, age, gender and ACG weights were studied. Multiple linear regression analyses were performed in order to explain and estimate patient costs.ResultsThe variation in individual patient costs was substantial within age groups as well as within ACG weight groups. About 37.7% of the individual patient costs could be explained by ACG weights, and age and gender added about 0.8%. The individual patient costs in 2001 estimated 22.0% of patient costs in 2002, whereas ACG weights estimated 14.3%.ConclusionACGs was an important factor in explaining and estimating individual patient costs in primary health care. Costs were explained to only a minor extent by age and gender. However, the usefulness of the ACG system appears to be sensitive to the accuracy of classification and coding of diagnoses by physicians.

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“…In 2006, a Swedish study found that the variation in individual patient costs was substantially different within different age groups, as well as within different co-morbidity groups. 13 37.7% of individual patient costs in the Swedish study could be explained by co-morbidities, while age and gender accounted for an additional 0.8%.…”

Development and Validation of a Score for Adjusting Health Care Costs in General Practice

“…Furthermore, they are proprietary systems, which are not transparent and difficult to use. The ACG system has been demonstrated to be sensitive to the accuracy of classification and coding of diagnoses by GPs, thus introducing potential bias into the estimates of practices' morbidity scores [8]. Other case-mix systems, such as that based on 17 Quality of Framework concepts [44], have demonstrated better performance than ACG (R 2 ¼ 0.31 vs. R 2 ¼ 0.27) in the United Kingdom.…”

“…Although the ACG seems to be the most valid method for predicting patient or health service costs, it is a proprietary risk adjustment system that tends to be not transparent, very expensive, and difficult to understand for the final user [8,16,17]. In addition, the 68 mutually exclusive ACG categories are not specifically targeted at patients with chronic disease, and are unable to sufficiently capture the prospective burden of chronic coexistent diseases [16,17].…”

“…General practice represents the most relevant setting for a cost assessment because general practitioners (GPs) constitute the primary access to health services, and control the diagnosis, management, prescribing, and referral of patients with chronic diseases. Previous studies conducted in the primary care setting in the United States reported mean yearly costs of $1376 to $2655 per patient [5][6][7]; in Europe, Engstrom et al [8] estimated the mean yearly costs to be between 978 and 6525 SEK (€106-€709; exchange rate June 2001) per patient, increasing the complexity of the Adjusted Clinical Group (ACG) clusters.…”