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



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.

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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.

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

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Correspondence to Siok Swan Tan.

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This study was conducted on behalf of the EuroDRG group (

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Tan, S.S., Chiarello, P. & Quentin, W. Knee replacement and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries. Knee Surg Sports Traumatol Arthrosc 21, 2548–2556 (2013).

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