Feature / HRG4: the final chapters

The last part of our guide to the new healthcare resource groups looks at: multiple trauma, emergency and urgent care, rehabilitation, immunology, infectious disease, critical care and high-cost drugs

V Multiple trauma, emergency and urgent care and rehabilitation

Chapter V is broken down into three sub-chapters: VA (multiple trauma), VB (emergency and urgent care) and VC (rehabilitation).

The multiple trauma HRGs include high-resource, complex treatments associated with multiple trauma cases (simultaneous injuries involving more than one body site). There are eight HRGs in the sub-chapter: five are procedure-based such as VA01Z (craniotomy for multiple significant trauma with major non-traumatic complications/comorbidities) and three based on diagnosis. The HRGs recognise the costs that may be incurred when trauma affects more than one body system. This concept did not exist in version 3.5, with most of this activity being reported in chapter H, musculoskeletal system.

The diagnosis can make a major difference to assignment of HRG. For instance, a road accident patient with a fractured skull (ICD-10 diagnosis S02.9 – fracture of skull and facial bones part unspecified – plus V43.5 – car occupant injured in collision with car) would group to the nervous system HRG AA26Z (muscular balance, cranial or peripheral nerve disorders, epilepsy, head injury). But with an additional ICD diagnosis of fracture of acetabulum, the patient would be grouped to the multiple trauma HRG VA07Z (head, chest and lower limb diagnoses of multiple significant trauma).

Three more HRGs in the emergency and urgent care sub-chapter (VB) brings the total to 11. The new HRGs cover three types of emergency department – 24 hour, consultant-led with full resuscitation facilities (type 1); consultant-led mono-specialty accident and emergency services such as ophthalmology or dental (type 2); and minor accident and emergency services (type 3). Under 3.5, types 2 and 3 were not covered but a new commissioning data set for accident and emergency has extended the coverage.

The 11 HRGs are described using combinations of three different categories of investigation with five different categories of treatment, with VB01Z (any investigation with category 5 treatment) the most resource intensive and VB11Z (no investigation with no significant treatment) the least. There is also a separate HRG covering dental care (VB10Z). Better reflection of costs has also been achieved by adding new treatments to the clinical data set used for emergency care. So, for instance, blood product transfusions and active rewarming of a hypothermic patient can now be captured. Earlier HRGs also only considered the investigations undertaken and the discharge type. So two patients given X-rays, one receiving CPR resuscitation the other having plaster of Paris applied for a broken wrist, would have been assigned the same HRG under the earlier HRGs (V01 high-cost imaging). Under HRG4, however, the wrist maps to VB07Z (category 2 investigation with category 2 treatment) while the resuscitation triggers VB01Z (any investigation with category 5 treatment). Given the different level of resources consumed by these interventions, HRG4 clearly provides an improvement.

The 23 rehabilitation HRGs are new to HRG4 and include three for assessments and 20 covering actual rehabilitation according to patient need. Rehabilitation HRGs are only generated where care takes place under a specialist rehabilitation consultant or within a discrete rehabilitation unit, in line with the Connecting for Health coding guidance which stipulates when rehabilitation OPCS codes should be recorded. The HRGs cover a range of forms of rehabilitation, including rehabilitation following hip fracture or joint replacement, rehabilitation following a brain injury and rehabilitation following stroke. The HRG4 design best serves general rehabilitation. Work is ongoing to refine the HRGs with regard to specialist, and complex specialised rehabilitation services.

Rehabilitation has been one of the areas the Department of Health has focused on for unbundling. But until now the unbundling has only covered stripping out rehabilitation costs from the tariff covering the acute phase, rather than setting a tariff for discrete rehabilitation, which remains covered by local contracts. HRG4 provides the framework for such a tariff but requires further development in some instances.

Across the whole chapter the 42 HRGs would have covered 29,000 finished consultant episodes (FCEs) during the first six months of 2006/07, excluding the accident and emergency activity which is at attendance rather than episode level. The single biggest contributor to this total was VA07Z (head, chest and lower limb diagnoses of multiple significant trauma) which accounted for 17,000 FCEs. The multiple trauma activity, while low volume, is expected to be high cost.

W Immunology, infectious diseases and other contacts with health services

This chapter allows for a number of different interventions not covered elsewhere. There are three sub-chapters: WA (immunology, infectious diseases, poisoning, shock, special examinations, screening and other healthcare contacts); WD (treatment of mental health patients by non-mental health service providers), and WF (non-admitted consultations). The sub-chapter naming is deliberate to leave room for development.

Sub-chapter WA reflects an improvement in granularity. In 3.5, the corresponding chapter S included haematology. This has remained a separate sub-chapter within the S chapter, leaving WA to focus on the non-specific conditions and interventions. The 18 non-specific HRGs within chapter S under version 3.5 have expanded to 58. For example, ‘other viral illness’ would have mapped to HRG S14 under 3.5. Under HRG4, there are five HRGs – two for viral illnesses or non-viral infections with or without complications/comorbidities and one for complex infectious diseases.

Sub-chapter WD contains the HRGs for treatment of mental health patients by non-specialist providers. These HRGs resided in the old chapter T, which under HRG4 is reserved for mental health services provided by specialist mental health providers.

Chapter T under version 3.5 had 17 HRGs to categorise cases according to mental health diagnosis – a method that proved ineffective. Under HRG4, the classification has been reduced to three HRGs that represent a split of cases by age: WD11Z (patients older than 69), WD22Z (ages 19 to 69) and WD33Z (under-19s). The names have been chosen to allow for more detailed groupings in future. The HRGs are not measures of casemix or intended to be used as the basis for tariffs, but complete the classification while mental health currencies are developed to support payment by results.

WF is a sub-chapter dedicated to non-admitted consultations, an area not covered in version 3.5. HRG4 is designed to be setting-independent. If a procedure is carried out in outpatients, it receives the same HRG as for an inpatient case. For example, a bilateral vasectomy carried out in outpatients would map to LB33Z (vasectomy procedures). Where little information is recorded, two global non-admitted HRGs have been created: WF01Z (non-admitted attendance) and WF02Z (multi-professional non-admitted attendance).

Across the chapter there are 70 HRGs. Some 311,000 FCEs would have mapped to these groups during the six months from April 2006, excluding outpatient attendance activity. The major contributors were WD22Z (patients older than 19 and younger than 69 with a mental health primary diagnosis [treated by a non-specialist mental health service provider]), which accounted for 68,000 FCEs during the period, and WA11Y (poisoning, toxic, environmental and unspecified effects without CC) at 30,000.

X Critical care and high cost drugs

This chapter includes unbundled HRGs covering critical care and high cost drugs. It breaks into four sub-chapters: XA, XB and XC (neonatal, paediatric and adult critical care), and XD (high cost drugs).

Neither neonatal or paediatric critical care were covered by HRG version 3.5. As unbundled HRGs, these groups are assigned in addition to a core HRG and are applied on a per day basis. Neither of these two sub-chapters is included in an HRG4 grouper product as the underlying minimum data set only becomes mandated on 1 April 2008. The six neonatal and eight paediatric groups include HRGs for transportation/retrieval, which are generated from the admitted patient care dataset rather than the critical care minimum datasets.

The eight HRGs in adult critical care sub-chapter XC are assigned on the basis of the number of organs being supported, with six supported organs mapping to XC01Z and XC07Z corresponding to no supported organs. The unit of currency for adult critical care is the critical care period, rather than the per diem HRG4 generation for neonatal and paediatric critical care.

The XD high cost drugs sub-chapter uses a straightforward structure with a one-to-one mapping of high cost drug OPCS codes to high cost drug HRG. Some drugs are divided into bands such as primary pulmonary hypertension drugs, which cover four bands and translate into HRGs XD01Z to XD04Z. The exceptions to this one-to-one mapping are .8 and .9 OPCS codes. All .8 codes map to XD35Z (other specified high cost drugs) and all .9 codes go to XD36Z (unspecified high cost drugs).

High cost drugs were not covered in version 3.5. Instead, their costs were subsumed within the admitted patient care HRGs. In total, the chapter covers 58 HRGs.


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