Disability, clinical complexity, and diagnosis-related groups in old patients

SIR—We read with great interest the important paper by Carpenter et al. on the relationship between physical disability, length of stay, and diagnosis-related group (DRG) reimbursement in hospitalised people [1]. We would like to contribute to the discussion on this topic presenting data obtained in 4,094 elderly patients (female = 61.5%, mean age = 79.4 ± 7.8 years) consecutively admitted to our ward. Our ward is modeled on the US ACE units [2, 3] and 78% of our patients are admitted through the emergency room. A multidimensional evaluation, including information on demographics, cognitive and affective status, physical health, functional abilities, and social support was performed on the first day after admission using a standard protocol, by a trained staff of geriatricians. Physiological severity was computed using the Apache II score taking into account the degree of abnormality of multiple physiological variables, age and chronic coexistent conditions (e.g. CHF, COPD, cirrhosis, renal failure, and cancer) [4]. Self-reported disability in basic activities of daily living (BADL) was assessed using the Barthel Index (BI) [5]. Seven different levels of disability were considered. As shown in Figure 1, a decrease of BI score detected on admission paralleled an increase in APACHE II score and DRG weight.