Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 21, Issue 11, pp 2548–2556 | Cite as

Knee replacement and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries

  • Siok Swan TanEmail author
  • Pietro Chiarello
  • Wilm Quentin



Researchers from 11 countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their Diagnosis-Related Group (DRG) systems deal with knee replacement cases. The study aims to assist knee surgeons and national authorities to optimize the grouping algorithm of their DRG systems.


National or regional databases were used to identify hospital cases treated with a procedure of knee replacement. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97 % of cases. Five standardized case scenarios were defined and quasi-prices according to national DRG-based hospital payment systems ascertained.


Grouping algorithms for knee replacement vary widely across countries: they classify cases according to different variables (between one and five classification variables) into diverging numbers of DRGs (between one and five DRGs). Even the most expensive DRGs generally have a cost index below 2.00, implying that grouping algorithms do not adequately account for cases that are more than twice as costly as the index DRG. Quasi-prices for the most complex case vary between €4,920 in Estonia and €14,081 in Spain.


Most European DRG systems were observed to insufficiently consider the most important determinants of resource consumption. Several countries’ DRG system might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities. Ultimately, this would contribute to assuring adequate performance comparisons and fair hospital reimbursement on the basis of DRGs.

Level of evidence

Retrospective comparative study, Level III.


Knee arthrosis Knee fracture Knee replacement Diagnosis-Related Groups Europe Economics 



The results presented in this paper were generated as part of the project ‘Diagnosis-Related Groups in Europe: Towards Efficiency and Quality (EuroDRG)’, which was funded by the European Commission within the Seventh Framework Research Programme (Grant Agreement Number FP7-223300). The authors are grateful to all our project partners who made this work possible. They particularly thank Reinhard Busse, Francesc Cots, Leona Hakkaart-van Roijen, Martin van Ineveld and Ken Redekop for their contribution to this study.

Conflict of interest

The authors have no conflicts of interest regarding the contents of this paper.


  1. 1.
    Best JT (2005) Revision total hip and total knee arthroplasty. Orthop Nurs 24:174–179PubMedCrossRefGoogle Scholar
  2. 2.
    Bozic KJ, Durbhakula S, Berry DJ, Naessens JM, Rappaport K, Cisternas M, Saleh KJ, Rubash HE (2005) Differences in patient and procedure characteristics and hospital resource use in primary and revision total joint arthroplasty: a multicenter study. J Arthroplasty 20:17–25PubMedCrossRefGoogle Scholar
  3. 3.
    Busse R, Geissler A, Quentin W, Wiley MM (2011) Diagnosis-Related Groups in Europe: moving towards transparency, efficiency and quality in hospitals. Open University Press and WHO Regional Office for Europe, Buckingham, pp 1–458Google Scholar
  4. 4.
    Casemix Service (2008) HRG 4 design concepts. The Information Centre, National Health Service (NHS), Leeds, pp 1–42Google Scholar
  5. 5.
    Cots F, Chiarello P, Salvador X, Castells X, EuroDRG group (2012) Patient classification systems and hospital costs of care for knee replacement in 10 European countries. Health Econ 21(Suppl 2):116–128PubMedCrossRefGoogle Scholar
  6. 6.
    Cots F, Elvira D, Castells X, Dalmau E (2000) Medicare’s DRG-weights in a European environment: the Spanish experience. Health Policy 51:31–47PubMedCrossRefGoogle Scholar
  7. 7.
    Effenberger H, Rehart S, Zumstein MD, Schuh A (2008) Financing in knee arthroplasty: a benchmarking analysis. Arch Orthop Trauna Surg 128:1349–1356CrossRefGoogle Scholar
  8. 8.
    InEK (2011) Vorschlagsverfahren zur Einbindung des medizinischen, wissenschaftlichen und weiteren Sachverstandes bei der Weiterentwicklung des G–DRG-Systems für das Jahr 2012. Institut für das Entgeldsystem im Krankenhaus (InEK), Siegburg, pp 1–9Google Scholar
  9. 9.
    Kimberly JR, Gd Pouvourville, D’Aunno TA (2008) The globalization of managerial innovation in health care. Cambridge University Press, Cambridge, pp 1–394CrossRefGoogle Scholar
  10. 10.
    Prismant Kiwa (2008) Hospital data project phase 2: final report. The need for metadata and data. Kiwa Prismant, Utrecht, pp 1–54Google Scholar
  11. 11.
    Kobel C, Thuilliez J, Bellanger MM, Pfeiffer KP (2011) DRG systems and similar patient classification systems in Europe. In: Busse R, Geissler A, Quentin W, Wiley MM (eds) Diagnosis-Related Groups in Europe: moving towards transparency, efficiency and quality in hospitals, 1st edn. Open University Press and WHO Regional Office for Europe, Buckingham, pp 37–58Google Scholar
  12. 12.
    Koechlin F, Lorenzoni L, Schreyer P (2010) Comparing price levels of hospital services across countries: results of pilot study. OECD Health, Paris, pp 1–59CrossRefGoogle Scholar
  13. 13.
    OECD (2012) OECD Health data 2012. Organisation for Economic Co-operation and Development (OECD), Paris,
  14. 14.
    Patris A, Blum D, Girardier M (2001) A change in the French patient classification system. CASEMIX Q 3(34):128–138Google Scholar
  15. 15.
    Quentin W, Scheller-Kreinsen D, Geissler A, Busse R, on behalf of the EuroDRG group (2012) Appendectomy and diagnosis-related groups (DRGs): patient classification and hospital reimbursement in 11 European countries. Langenbecks Arch Surg 397:317–326PubMedCrossRefGoogle Scholar
  16. 16.
    Reid B, Sutch S (2008) Comparing diagnosis-related group systems to identify design improvements. Health Policy 87:82–91PubMedCrossRefGoogle Scholar
  17. 17.
    Sanchez-Martinez F, Abellan-Perpinan JM, Martinez-Perez JE, Puig-Junoy J (2006) Cost accounting and public reimbursement schemes in Spanish hospitals. Health Care Manag Sci 9:225–232PubMedCrossRefGoogle Scholar
  18. 18.
    Schreyogg J, Stargardt T, Tiemann O, Busse R (2006) Methods to determine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries. Health Care Manag Sci 9:215–223PubMedCrossRefGoogle Scholar
  19. 19.
    Soderlund N, Gray A, Milne R, Raftery J (1996) Case mix measurement in English hospitals: an evaluation of five methods for predicting resource use. J Health Serv Res Policy 1:10–19PubMedGoogle Scholar
  20. 20.
    Street A, Scheller-Kreinsen D, Geissler A, Busse R (2010 May) Determinants of hospital costs and performance variation: methods, models and variables for the EuroDRG project. Working papers in health policy and management 3Google Scholar
  21. 21.
    Tan SS, van Ineveld BM, Redekop WK, Hakkaart-van Roijen L (2010) Structural reforms and hospital payment in the Netherlands. EuroObserver 12:7–9Google Scholar
  22. 22.
    Wilson NA, Schneller ES, Montgomery K, Bozic KJ (2008) Hip and knee implants: current trends and policy considerations. Health Aff 27(6):1587–1598CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Siok Swan Tan
    • 1
    Email author
  • Pietro Chiarello
    • 2
  • Wilm Quentin
    • 3
  1. 1.Institute for Medical Technology AssessmentErasmus Universiteit RotterdamRotterdamThe Netherlands
  2. 2.Servei d′Epidemiologia i Avaluació - Parc de Salut Mar (PSMAR)Hospital del MarBarcelonaSpain
  3. 3.Department of Health Care ManagementTechnische Universität BerlinBerlinGermany

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