Introduction

The Department of Health determined that, from April 2011, Trusts would not be paid for emergency readmissions within 30 days of discharge. The purpose of our project was to identify factors associated with such readmissions and implement plans for improvement.

Introduction. We conducted an audit on hip fractures to analyse the accuracy of coding and payment by results in our institution. Materials/Methods. The initial audits analysed hip fracture over a period of four months at two different trusts. Case notes were reviewed to extract data regarding diagnosis, comorbidities and operative procedures. The findings were compared with the data from clinical coding department and difference in the tariff was analysed. A re-audit was performed at Trust B after implementation of changes to assess improvement. Results. In the initial audit 111 patients were reviewed. Twenty-three percent patients had all data correctly coded. In the remaining 77%, some of the co-morbidities had been missed, e.g. UTI, anaemia and osteoporosis etc. 11.7% of operative procedures and 16.5% of fracture patterns were incorrectly coded resulting in loss of £53 000 over the 4 month period. Poor documentation and the use of ‘uncodable’ language by clinicians were responsible for missing co-morbidities, while inadequate medical knowledge of clinical coders resulted in the incorrect recording of operative procedures. We implemented changes in the form of clinical coders training, awareness of “codable words” by medical staff and writing the procedure codes by the surgeons themselves. A re-audit at Trust B showed an estimated savings of £18540.00 over 3 months period, demonstrating a significant improvement. Conclusion. Inaccuracies in clinical coding result in loss of tariff. Awareness of codable words, writing the operative codes by surgeons and training of clinical coders can improve clinical coding and payment by results in NHS hospitals

Aims. To devise a simple clinical risk classification system for patients undergoing primary total knee arthroplasty (PTKR) to facilitate risk and cost estimation, and aid pre-operative planning. Methods. We retrospectively reviewed a series of consecutive PTKRs performed by the senior author. A classification system was devised to take account of principal risk factors in PTKR. Four groups were devised: 1) Non complex PTKR (CP0): no local or systemic complicating factors; 2) CPI: Locally complex: Severe or fixed deformity and/or bone loss, previous bony surgery or trauma, or ligamentous instability; 3) CPII Systemic complicating factors: Medical co-morbidity, steroid or immunosuppressant therapy, High BMI, (equivalent to ASA of III or more); 3) CPIII: Combination of local and systemic complicating factors (CPI+CPII). The patients were grouped accordingly and the following were compared: 1) length of stay, 2) post-operative complications, and 3) early post-discharge follow-up assessment. The complications were divided into local (wound problems, DVT, sepsis) and systemic (cardiopulmonary, metabolic, and systemic thromboembolic) complications. Results. The total number of patients was 119 (CP0=37,CPI=19,CPII=30,CPIII=33). Multiple regression analysis revealed: 1) no significant difference between complication rates in the CP0 and CPI groups, 2) 3-fold and 4-fold increase in the cumulative risk in the CPII and CPIII groups respectively (p<0.001), 3) significantly increased length of stay in the CPII and CPIII groups (p<0.001). Conclusion. The groups in this classification system correlate well with complication rates from surgery. As such this system has a role in stratifying patients for pre-operative planning and risk counselling. It is reproducible and can be used for larger patient groups via the National Joint Registry. Our findings also have implications for payment by results and fixed tariffs for PTKR, as the higher complication rates in the CPII and CPIII groups are likely to attract greater expense by hospitals in the course of these patients' treatment