Abstractt Health

BMC Health Services Research 2012, Volume 12 Suppl 1
http://www.biomedcentral.com/bmchealthservres/supplements/12/S1
MEETING ABSTRACTS
Open Access
Proceedings of the 6th International Casemix

Conference 2012 (6ICMC2012) - Moving Beyond
The Casemix Frontier: Towards Sub-Acute and
Non-Acute Classifications
Kuala Lumpur, Malaysia. 6-7 June 2012
Edited by Syed Mohamed Aljunid, Sharifa Ezat WP, Saperi bin Sulong, Aniza Ismail, Amrizal Muhammad Nur,
Zafar Ahmed, Nurhizam Safie, Harleen Kaur, Irwan Saputra, Suzainur KARs and Norshamiza Abdul
Published: 21 November 2012
These abstracts are available online at http://www.biomedcentral.com/bmchealthservres/supplements/12/S1
INVITED SPEAKER PRESENTATIONS

I1
Is the international classification of healthcare procedures (ICHI)
a critical point for the implementation of an international
Casemix grouper?
Jean-Marie Rodrigues
Emeritus PCS International, Saint Etienne Medical School, University of Saint
Etienne Jean Monnet, France
BMC Health Services Research 2012, 12(Suppl 1):I1
Most of developed countries have kept on maintaining, updating and
modifying their own coding systems for procedures, as well as national
adaptations of ICD, in order to manage and to fund their health care
delivery. The most significant efforts were done in Australia with ACHI
(Australian Classification of Health Interventions) or ICD10 AM, in Canada
with the Canadian Classification of Health Interventions (CCI) developed by
the Canadian Institute for Health Information (CIHI) and in France with
CCAM (Classification Commune des Actes Mdicaux). For some decades
several broad pre-coordinated or compositional systems have been
proposed to users targeting different goals. The most well known are the
UMLS (Unified Medical Language System), LOINC for clinical laboratories,
DICOM SDM for imaging, SNOMED, Convergent Medical Terminology
(CMT).
Since 2010 WHO FIC has developed ICHI to describe health intervention
defined as an activity performed for, with or on behalf of a client(s) whose
purpose is to improve individual or population health, to alter or diagnose
the course of a health condition or to improve functioning. This definition
includes interventions that apply to more than one client or to a population
group. As a consequence the prospective international classification will
include interventions across the whole health system. It would include
interventions provided by all types of providers: doctors, dentists, nurses,
allied and community health workers, traditional medicine providers and
public health practitioners. The aims of this international classification are to
1) describe and compare the provision and effectiveness of health
interventions at the local, national or international level.
2) provide a classification of appropriate scope and detail to which
countries may align their more finely grained national or specialty
classifications.
3) ensure that a classification is available that can be used without

adaptation in countries which do not wish to further refine the classification.
4) take into account that interventions include elements of western and
traditional medicine.
ICHI is now a procedures classification with the level of granularity of ICD9-CM Volume 3. It is an incentive able to harmonize between the national
classifications of health interventions. Such Countries interested in
comparability of data including Casemix systems analyzed by an international Casemix grouper should modify their existing systems partially to
be compliant with the framework but are not mandated to change the full
terminology they use. For countries without an interventions classification
and namely developing countries it can be used directly.
ICHI is providing the opportunity to compare the performance of different
health care systems using an international Casemix grouper.
I2
Casemix system in Nordic countries
Olafr Steinum
Rrviksvgen 19, SE-451 77 Uddevalla, Sweden
The five Nordic countries are characterized by stable political systems based
on consensus and interactive contracts between the populations and their
governments. There has been a prosperous development through more
than half a century, which also has resulted in a model of good health care
for all. However from late part of 1980s and during the 1990s it was realised
that the cost of health care escalated beyond what was considered to be
sustainable.
The concept of Casemix was introduced to all the Nordic countries over a
few years in the 1990s, but the implementation of Casemix systems
differed considerably between the five countries.
From 1966 the NOMESCO (Nordic Medico-Statistical Committee) presented
statistical analyses to facilitate comparisons between the Nordic countries,
and based on experiences from the NOMESCO collaboration, the Nordic
Centre for Classifications in Health Care was established as a WHO
Collaborating Centre in 1987.
The Centre has been a common arena to develop and manage health
classifications (NCSP, NCECI) and the NordDRG Casemix grouper, as well
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Page 2 of 10
as support to the WHO ICD-10 update process with views from the
Nordic medical profession.
At the presentation elaboration on the historical development will be given
with focus on the various paths of development, which the Casemix
concept took in each of the Nordic countries. The differences in governance
(state engagement or not) are discussed, as is the need for knowledge and
education. Innovation and future trends will be mentioned.
developments are needed to document knowledge generation related to

health system outcomes via financing initiatives.
Conclusion: Health finance and Casemix research need long-term
commitment of a development team to refine results to find ways of
implementing into health systems as well as to evaluate whether favorable
changes happen.
I3
Developing sub-acute, non-acute and special groups in the
universal grouper
Syed Mohamed Aljunid
United Nations University International Institute for Global Health (UNU-IIGH),
Kuala Lumpur, Malaysia
The use of Casemix system as providers reimbursement method under
social health insurance schemes has spread beyond high-income countries.
Over the last decade many low and middle-income countries (LMIC) have
started to implement Casemix system to replace the conventional yet
inefficient fee-for-service as provider payment mechanism. UNU-IIGH
launched an international grouper called UNU-CBG in 2010 to support the
implementation of Casemix system in LMIC. To date, UNU-CBG has been
introduced in 12 countries in different phases of implementation process.
UNU-CBG was designed to function as an international grouper that can be
customized and adapted to suit the local needs and norms of each country.
However inability to provide robust groupings for sub-acute and chronic
conditions is a major limitation in the use of Casemix system in these
countries. Sub-acute and chronic diseases that account for more than two
thirds of disease burden in LMIC should be categorized in mutually exclusive
groups if the reimbursement were to be made using Casemix system.
Researchers in UNU-IIGH and International Casemix and Clinical Coding
Centre of UKM have been working very hard for the past two years to
upgrade the capacity of UNU-CBG grouper to classify sub-acute and chronic
cases into Casemix group. Additional variables included in the new
grouping algorithm are extended length of stay, costly prostheses, drugs,
procedures, investigations and scores of Activity of Daily Living. The new
version of UNU-CBG launched during this conference provides an
opportunity for social health insurance managers in LMIC to use Casemix
system as a total solution for provider payment method.
I4
Developing sub-acute and non-acute Casemix classification:
the Thailand experience
Supasit Pannarunothai
Centre for Health Equity Monitoring, Faculty of Medicine, Naresuan
University, Thailand
Background: The needs for other modes of care apart from acute
hospital care have long been realized but minimal integrated efforts have
developed so far. Payment mechanism is a strong financing strategy to
create favorable changes in the health systems.
Objective: This session is to illustrate the rationale and progress of the
developments of sub-acute and non-acute Casemix classification as a
financing mechanism in Thailand.
Method: Review of literature of the last five years is the main data
collection.
Result: The rehabilitative medicine has been an established discipline for
over four decades in Thailand while psychiatry even longer. Complaints
from health care providers of being underfunded activities have been
around since the third revision of Thai Diagnosis Related Group since 2001.
The fifth revision of TDRG set the goal of accomplishing other Casemix
classifications apart from DRG for acute inpatient care, two Casemix
systems for inpatient psychiatric and rehabilitative care were submitted to
the National Health Security Office in 2011. The NHSO anticipated the
difficulties of implementing the two new Casemix systems as initiative
payment methods. Two separate streams of putting the Casemix products
to the health systems were designed. Further follow-ups of these
I5
Implementation of Casemix system in Hospital Universiti Sains
Malaysia by using UNU-CBG grouper: is it feasible to support
apex programme?
Rosminah Mohamad
School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan,
Malaysia
Background: The framework of Accelerated Programme for Excellence
(APEX), modeled on the German Universities Excellence Initiative, is
profoundly important and decisive initiative for Malaysian higher
education. The selection of USM under APEX initiative is based on the
universitys state of readiness, preparedness and transformation plan for
change that focused on diagnostics, medical biotechnology, waste
management, pharmaceuticals, nano-technology, membrane technology
and vaccines. Becoming an APEX University, HUSM indeed is committed
to achieve certain goals in their functions as teaching and referral
hospital in the east cost of Peninsular Malaysia. One of the priority goals
is to ensure that resources and allocation for each department within
hospital is sufficiently distributed to ensure health care delivery is
efficient and maintain at high quality to the patient. Selection of UNUCBG Grouper is justified from the universal and dynamic functions of this
Grouper that able to cater for various severity levels and able to capture
an Acute (in-patient and outpatient), Sub-Acute (moderately complex
cases) as well as Chronic Case (long stay cases) patients.
Study objective: To preliminary observe the feasibility of using UNU-CBG
Grouper as a grouping tool for Casemix HUSM.
Methodology: Data mining of inpatient record discharged from HUSM
within fiscal year 2009 and 2010 was done from Hospital Information
Management System (HIMS). Data was transformed into Excel formatted
sheet and exported into UNU-CBG Grouper software for further categorization and grouped into MY-DRGs and CBGs based on UNU-CBGs code
classification system. Since HUSM is yet having the hospital tariff, UKMMC
tariff was applied in this study by taken into consideration various similarities
identified between these two teaching hospitals. We assumed the hospital
tariff more or less will be the same between HUSM and UKMMC for us to fit
the purpose of this preliminary study. MY-DRG codes for HUSM were
generated from the Grouper, whereby the CBG cost weight was generated
via integration of CCM software. Therefore, the CBG cost for HUSM patients
was then determined. In order to observe the variance of charges between
patient charges charged based on the Payment Guideline Schedule set by
Finance Unit, HUSM and CBG cost, patient charges for three departments;
Surgery, Orthopedics and Obstetrics, and Gynecology departments was
reviewed. The charges were then quantitatively analyzed for the charges
differential.
Result: HUSM respectively exhibit 747-bed complement and occupancy
rate of 68 patients per bed. The hospital has 5 days ALOS. Department of
Surgery (4,932 admission), Orthopedics (3,694 admission) and, Obstetrics
and Gynecology (8,525 admission) are among top ten departments that
received highest admission within this two years. 83.6% (15,187 cases) of
the admission were cases from A & E Department. The ALOS for each
department in this study was 4 days, 6 days and 2 days, respectively.
Average charge on patients that based on itemized procedures and
consumables compared to CBG costs showed relatively low charges and
significantly different at p < 0.005 with the mean different of RM5, 356.92
(SD- RM 3,409.48; SE- RM 695.96).
Discussion: The importance of transforming HUSM to a more efficient
hospital management system clearly presented from this pilot study. This
scenario may contribute to the lower efficiency and low quality of
healthcare services due to the insufficient budget allocated each year that
is traditionally based on the previous year hospital expenditure. Unlike the
traditional per diem costing (which is very crude) costs that daily rates are
established for specific hospital departments and represent the average

Page 3 of 10
cost of hospitalization in specific departments, costs per weighted case

capture the cost of hospitalization of a patient in a specific condition and
are usually classified according to clinical diagnoses. Interestingly, the DRG
system allows only one DRG assignment per patient episode, whereby
payment will includes all services that occur between hospital admission
and discharge. Grouping patients in this manner allows hospitals to
evaluate and manage costs by DRG or groups of DRGs. Hope this research
could deliver beneficial information to health care provider in HUSM and
provide Health Campus community with such an up-to-date hospital
management system.
Conclusion: Minimal refinement on the coding and the framework on the
HIMS is needed in order to cater the requirement for the Casemix System in
HUSM. Decision to implement Casemix System as a hospital management
tool is possible to enhance efficiency and quality of hospital delivery system
in HUSM. Hence, aligned with the mission to support the APEX programme
in USM. Therefore, it will be taken with high expectation to achieve
efficiency, solidarity (fairness and equity).
considers rehabilitation and medical service highly in their hierarchical

system suitable as a sub-acute classification system.
Development of Casemix system for sub-acute care: There are three
important components when we are developing the Casemix system for
sub-acute care.
1. Independent variables: such as patient functioning, disease category
and aim of service use.
2. Outcome variables; such as work provided by health care Professionals.
3. Incentives for facilities and client.
These three components are interactively related. A weekly patients
assessment in RUG assessment system gave nursing homes toward early
discharge of the patient from Medicaid paid facilities. In contrast the
nursing home tends to take patients with severe functional problem in
Japanese system, regardless of their length of stay.
Future of the sub-acute Casemix system with the ICF: The WHO has
implemented the International Classification of Functioning, Disability and
Health (ICF) in 2001. The ICF provides a broad description of functioning
in the form of hierarchical categories and can be used as common
taxonomy among health care Professionals internationally. The adaptation
of the ICF as common taxonomy to be used in sub-acute case mix
system may solve problems of current sub-acute case mix systems.
A Japanese experience of ICF adoptation in patient management will be
discussed.
I6
Integrating Casemix system in to the Philippine social health insurance
Maria Josefina A Gool
Philippine Health Insurance Corporation, Philippines
The Philippine Health Insurance Corporation (PhilHealth) is a government
owned and controlled corporation, established in 1995 and tasked to
implement the National Health Insurance Program. Since its inception,
PhilHealth has utilized the fee-for-service scheme for majority of inpatient
benefits and case payment for selected, mostly outpatient benefits.
In 2010, the country elected a new president and Universal Health Care was
declared a national agenda. The challenge for PhilHealth was not only to
ensure 100% coverage but provide true financial risk protection. One of the
identified key strategies was to shift to a new provider payment mechanism
that will foster patient empowerment through clear and predictable
financial support. In Sept 2011, PhilHealth rolled out the first 23 medical and
surgical case rates which accounts for 45% of all cases being reimbursed by
PhilHealth the previous years. Rates were determined by assigning weights
to previously obtained tariff rates, contracting rates for public and private
hospitals and average value per claim for the preceding years. The highest
computed rates were identified and used. Along with this, a zero copayment policy or No Balance Billing policy was instituted.
After almost 8 months of implementation, case payment scheme is proving
to be the only solution for PhilHealth to ensure member empowerment,
cost containment and claims processing efficiency. However, the problem
still lies in government not being able to provide the necessary medicines
and services that is already included in the case payment package. Despite
these challenges, 29 medical and 32 surgical illnesses more will be paid as
case rates. This will then account for 85% of cases being reimbursed by
PhilHealth until a time that these case rates will be converted to full case
mix.
The change in payment provider mechanism entails a big paradigm shift for
the whole health system. Reform interventions inside the corporation are
being done that will truly inform, empower and guide its members.
Expansion of benefit packages has started. Information technology infrastructure is in full swing and new engagement processes with providers are
being adapted. In the end, universal health care can be achieved by
re-awakening the spirit of solidarity among Filipinos, which is the very
essence of the National Health Insurance Program.
I7
Casemix system for the elderly persons in Japan
Jiro Okochi
Tatsumanosato Geriatric Health Services Facilities, Osaka, Japan
Background: Casemix classification systems for post acute care have been
developed in several countries. The paradigm of each system is different
depending on service and target population and the intension of the
system itself. Japanese classification system is more suitable for long-term
nursing care for elderly person. In contrast, RUGs system used in the US
I8
Development of ICD 11: changes and challenges
A Zafar1*, Sharifa Ezat WP2
1
International Training Center for Casemix and Clinical Coding, UKM Medical
Centre, Cheras Kuala Lumpur, Malaysia; 2Department of Community Health,
UKM Medical Centre, Cheras Kuala Lumpur, Malaysia
Hospitals are data hungry organization, and store tons of patient level data
in the patients clinical notes. This data cannot be used in the day to day
decision making because it is not standardized. That was the rationale that
started the movement to standardize the clinical documentation which
resulted in the development of clinical coding standards based on disease
classification. Disease classification has its roots in the classes of causes of
death, which started as early as mid 18th century. The classes for the causes
of death was formalized by the International Statistical Congress that later
evolved into the International Statistical Institute. International Statistical
Institute later collaborated with Health Organization of the League of
Nations, the precursor of the World Health Organization to incorporate the
classification of morbidities, and later on the role for updating and
maintenance was wholly taken over by the WHO.
The last revision (10th Revision) of the International Classification of Disease
was carried out in 1989 and is famously known as ICD 10. ICD 10 has served
its purpose very well, but with the rapid change in the technologies and
way the data is managed in hospitals, it is fast becoming obsolete. Therefore
WHO has decided to revise the current version of the ICD 10, and come up
with ICD 11 that fulfills all the requirements a modern healthcare system.
ICD 11 will be a comprehensive classification that can be used by all the
different stakeholders in the healthcare environment, can be integrated into
the digital hospital information system and other terminologies such as
SNOMED CT. For that purpose WHO has come up with a comprehensive
program to involve the different stakeholders in the development of the ICD
11 that hopefully, will be commissioned in 2015.
ORAL PRESENTATIONS
O1
Cost analysis of UMMC services: estimating the unit cost for
outpatient and inpatient services
Maznah Dahlui1*, Ng Chiu Wan1, Tan Seow Koon2
1
Julius Centre, department of Social and Preventive Medicine, Faculty of
Medicine, University of Malaya, Kuala Lumpur, Malaysia; 2University of Malaya
Medical Centre, Kuala Lumpur, Malaysia
E-mail: maznahd@ummc.edu.my
BMC Health Services Research 2012, 12(Suppl 1):O1

Page 4 of 10
Introduction: Hospital cost analysis is an essential tool relating the inputs

of resources in monetary terms to the outputs of services provided by
hospitals. Cost information is part of the basic information needed by
hospital managers and national policy makers to enable them to make
informed decisions to enhance performance of hospitals in a health care
delivery system and for efficient allocation of resources within or
between hospitals.
Objectives: The primary objective of the study was to determine the
actual costs of health care service provision, including costs for surgical
procedures, at the University of Malaya Medical Centre (UMMC) for the
calendar year 2010. The UMMC is the academic teaching hospital of the
University of Malaya and also a major tertiary referral hospital in Malaysia.
Methods: The study applied a top-down method and step-down allocation
of overhead costs to the final health care departments. The categories of
costs included in the estimation included costs for personnel, overheads and
the annualized costs of equipment associated with the treatment of patients
on an aggregate as well as a per capita basis. The final study outputs were
expressed as cost per visit for outpatient and daycare services as well as the
cost per diem and per admission for medical and surgical inpatient services.
Results: The average length of hospital stay (ALOS) for all admissions in
2010 was 6.30 days (SD 8.945) while the ALOS for the medical and surgical
wards were 6.7 days (SD 8.886) and 5.6 days (SD 9.005) respectively. The
costs per admission at the medical and surgical wards were RM 4,296 and
RM 6,073.71 respectively, while the cost per diem were RM 641.15 and RM
1,085.48, respectively. The average cost for a surgical procedure performed
at the operating theatre was RM 1084.59. The major cost component for the
medical wards was for consumables which made up 70% of the total cost
for the medical inpatient services. In contrast, costs for treatment
procedures made up 62% of total costs for the surgical inpatient services.
Although there were more medical wards and more medical admissions
compared to surgical wards and admissions, there was no significant
difference in the proportion of staff emoluments to the total cost for
medical and surgical inpatient services (approximately 11%). The costs per
outpatient and day-care visit were RM 239.19 and RM 777.24 respectively.
The proportion for consumables at the outpatient was half than that of daycare; consistent to the type of healthcare services given at day-care.
Conclusion: The costs per diem for medical inpatient services were 1.7
times higher than surgical services. The costs per visit for outpatient
services were 3.2 times higher than daycare. The study results are of use in
future economic evaluation studies in the UMMC to help identify the most
cost-effective modality of treatment for specific diseases as well as in the
determination of cost weights for case-mix hospital reimbursement system
in a major academic teaching hospital.
impact of DRGs on efficiency mostly focused on technical efficiency or

productivity. The findings were somehow mixed, there was some
evidence on improved technical efficiency (Portugal, Sweden, Norway)
but nothing significant in the US, Austria as well. The country specific
points and context may explain the divergent result.
Conclusion: DRGs contributed to enhance understanding of the
relationship between resource use and the activity in acute care setting.
Evidence from empirical studies of the impact of DRGs reimbursement on
hospital efficiency is mixed. While some research tentatively suggests
efficiency improvements, at least in the short-run, attributing these to
DRGs reimbursement is complicated by confounding factors.
O2
Impact of DRG reimbursement system on hospital efficiency:
systematic review
Hossein Moshiri Tabrizi
E-mail: moshiri49@gmail.com
Background: During the last two decades, most countries including
developed and developing have experienced a rapid increase in health
care expenditures in general, and hospital expenditures in particular. DRGbased reimbursement systems were introduced to control healthcare and
hospital expenditure, increase activity levels and standardize care. This
paper reviews the theoretical and empirical evidence on whether DRGs can
meet these ambitious objectives. The objective of this study is to
systematically review the effect of DRG payment system on hospital
efficiency and to find theoretical and empirical evidence that DRGs
enhance efficiency and effectiveness in the hospital sector.
Materials and methods: This study searched the EconLit and MedLine
databases for published articles in the English between 1984 and 2009.
Search terms included efficiency, Hospital efficiency, and frontier analysis.
These could be reduced to more relate using additional keyword such as
DRG reimbursement, DRG payment system. According to review objective
relevant studies have been selected.
Result: This paper reviewed 25 studies included all studies published in
refereed journals or books that were either published or available in preprint during the study period. According reviewed articles studies of the
O3
Data mining cluster analysis on the influence of health factors in
Casemix data
Harleen Kaur1*, Ritu Chauhan2, Syed Mohamed Aljunid1
1
United Nations University International Institute of Global Health (UNU-IIGH),
Malaysia; 2Hamdard University, New Delhi, India
E-mail: harleen.k@unu.edu
Background: This study explores potential data mining applications in the
Casemix context, which is expected to yield effective and efficient health
care services. The objective of work focuses on determining hidden relevant
patterns which cant be processed by human capabilities all alone. California
Drug and Alcohol treatment Assessment (CALDATA) of administrative type
database can be relevant study for the medical diagnosis in usage of alcohol
and drugs for patients admitted and discharged during the stay in hospital
to discover knowledge for recovery process.
Methods: We utilized the observational study on cases registered to
California Department of Alcohol and Drug Programs (ADP) to promote the
initiative for increasing availability of abusive drug usage data for better
drug recovery services among the California. The cases were diagnosed with
Minitab diagnostic tool to access the Casemix databases for retrieval of
hidden information using data mining tools. The K means clustering having
used with dendrogram to determine the possibility of existence of patient
admitted and discharged on the accountability for usage of abusive
substance between the years 1991-1993. The classification of data is done
among the educated and uneducated class for categorized race with
correlation age at the time of admission to hospital. The analysis has been
performed on the patients admitted due to abusive substance usage and
treatment provided during the stay in hospital and discharge status for final
medical diagnosis provided to patient those have suffered for long stay
during hospitalization.
Results: There has been a tremendous increase in the incidence rate of
admission cases in age group 45-49 years. The probability of over 40%
cases acquiring maximum number of abusive substance exists in patients
who have obtained post graduate education. The decline approximately
2.3% of criminal activities after proper diagnosis to patients with high level
of alcohol dependency among the cases observed.
The total number of cases evaluated to study was 1,826 in 1991-1993; total
number of features selected was 1,205 for each case diagnosed. The cases
were diagnosed on the basis of admission and discharge among the
prevalence of abusive substance usage. The subject was classified for
different subjects such as education, age, duration of stay in the hospital,
estimated reduction on criminal cases, decrement of hospital cases while
the treatment provided during the stay.
We calculated the overall usage of abusive substance among the
categorized race at time of admission with reference to the age. The results
shows white were among the categorized age group of 17 and under has
the maximum usage of abusive substance whereas native Americans are the
one those who have minimum consumption of abusive substance usage.
In diagnosis of longest time of stay during the treatment in hospital from
day of admission to day of discharge due to abusive substance usage we
have calculated the overall maximum number of prevalent cases during the
year 1991- 1993, we have found that longest stay was observed for male/
female aged below 17 years year and were correlated to marital status that
is unmarried. The clusters in the dendrogram has been observed, where the
largest cluster represents the maximum number of unmarried male/female
patients diagnosed for highest abusive substance usage, whereas the
second cluster represents the second highest cases for divorced/separated

Page 5 of 10
has the maximum usage of abusive substance, third cluster represent the
single between the age group 21-24 years accounted for 48% cases for
length of stay during hospitalization, fourth cluster represents the married
cases those who were among age group 35-39 years, the minimum number
of cases were studied for widowed.
Conclusions: The integrated approach, K-means and Hierarchical Clustering
technique using Minitab are well suited techniques to provide insight of
health service databases. The probability of patients acquiring the abusive
substance depends on several factors such as education, age, marital status
and several other factors related to patients. The discharge status of these
highly correlates to criminal activity and discharge status of hospitalization
cases which have reduced down tremendously after providing treatment to
admitted patients.
was to evaluate the effectiveness of Introduction to UNU-Casemix Grouper &

IT in Casemix System workshop which was conducted in Indonesia.
Method: A quasi-experimental pre-test and post-test research design was
conducted to evaluate the effectiveness of the program by measuring
change in pre-test and post test data. Data was collected from health staff
in Indonesia (representatives from selected Hospitals) who attended to
case-mix workshop which was a five days course of classroom-based
training conducted by United Nation University-International Institute for
Global Health (UNU_IIGH). A 20-item questionnaire provided the data. The
course aims to consolidate both the practical coding skills and theoretical
knowledge through a number of assessment based exercises and
interactive activities.
Result: In total, 106 questionnaires were distributed and 91 (86%)
were useable for the final analysis. The mean age of the participants was
37.85 years. 52.7% participants were male and 47.3% were female. 47.3% of
the study sample had attended to similar workshop before. The participants
mean score in the knowledge pre-test was 10.18, and 11.91 in post-test,
which increased significantly (t = 2.60, p = 0.01).
Conclusion: The finding of the evaluation of the workshop indicated that
the program improved the participants knowledge regarding case-mix
system and highlights the role of education. It is unquestionable that
education is a major factor in improving knowledge and understanding of
the funding system among staff and managers in hospitals and health
systems.
O4
Estimating clinical and economic burden of pneumococcal meningitis
in Malaysia using Casemix data
Namaitijiang Maimaiti1,2*, A Zafar1,3, M Amrizal1, Md Isa Zaleha2, S Saperi3,
Syed Aljunid1,2
1
United Nations University International Institute for Global Health, Kuala
Lumpur, Malaysia; 2Department of Community Health, UKM Medical Center,
Kuala Lumpur, Malaysia; 3International Centre for Case-Mix and Clinical
Coding, UKM Medical Centre, Kuala Lumpur, Malaysia
E-mail: memet_nu@yahoo.com
Background: Pneumococcal disease kills over 1.6 million people each year.
The vast majority of its victims come from developing countries. Meningitis
cases due to S. pneumoniae have one of the highest mortality rates in
pneumococcal diseases. However there is no data on clinical and economic
burden of pneumococcal meningitis (PM) in Malaysia. Aim of this study was
to estimates the clinical and economic burden of PM in Malaysia.
Methodology: The clinical and economic burden of pneumococcal
meningitis (ICD code G00.1) was assessed using a two years retrospective
review of patients medical records (2008-2009) from four public hospitals in
Malaysia. The cases of PM were identified the using ICD 10 diagnoses codes
and were assigned CBG group using MY DRG from UNU Casemix system.
Costs of PM were estimated based on the MY DRG using step down costing
methodology from hospital cost data. The annual cost of the disease was
stratified for pediatric and adult cases.
Result: There are 2,809 PM cases annually; out of these 1,392 belongs to
the pediatric age group while 1,417 were adult cases. Cost per episode of
pneumococcal meningitis was calculated. The cost for inpatient pediatric
pneumococcal meningitis was estimated as RM 6,027 while for inpatient
adult case was estimated as RM 4,985. The cost for pediatric outpatient
pneumococcal meningitis visit was RM 824 while that for adult case was
RM 515. Total direct cost for pneumococcal meningitis is estimated to be
RM 3,737,584, of which 52% (RM 1,785,811) were due to pediatric cases
while 48% (RM 1,951,773) were generated by adult cases in Malaysia.
Conclusion: PM is presented a significant burden for Malaysian population
and society. The disease burden can be reduced through vaccination.
O5
Evaluation of introduction to UNU-Casemix grouper & it in Casemix
system workshop for health staff in Indonesia
Azam Rahimi1,2*, Saperi B Sulong3, Mohamed Amin embi4,
Syed Mohamed Aljunid1
1
Lumpur, Malaysia; 2Department of Community Health, UKM Medical Center,
Kuala Lumpur Malaysia; 3International Training Centre for Case-Mix and
Clinical Coding (ITCC), UKM Medical Centre, Kuala Lumpur, Malaysia;
4
Faculty of Education, Universiti Kebangsaan Malaysia, Bangi, Selangor,
Malaysia
E-mail: rahimi997@yahoo.com
Introduction: Implementation of Casemix system needs a well-organized
and computerized system with well-trained and oriented staff, otherwise the
system will fail. Improving knowledge and understanding of the funding
system among staff and managers in hospitals and health systems can
provide the groundwork for service improvements. The aim of this study
O6
Rehabilitation service development for Sub-Acute and Non-Acute
Patient (SNAP) under universal coverage scheme in Thailand
Orathai Khiaocharoen1*, Supasit Pannarunothai2, Preeda Taearak3,
Wachara Riewpaiboon4, Chairoj Zungsontiporn5
1
Phitsanulok Provincial Health Office, Thailand; 2Centre for Health Equity
Monitoring (CHEM) Faculty of Medicine, Naresuan University, Thailand;
3
National Health Security Office Region 8 Udon Thani, Thailand; 4Health
Systems Research Institute (HSRI), Thailand; 5Central Office for Healthcare
Information, Thailand
E-mail: orathaik2000@gmail.com
The need of rehabilitation in sub-acute and non-acute patients has been
continuously increased. Rehabilitation services in Thailand are considered
only as part of acute care so that the providers are not motivated to provide
intensive services to patients because the payment based on diagnosis
related group focuses on acute phase. This study aimed to develop an
appropriate model for SNAP Casemix including in-patient, out-patient, and
home based care in 4 groups of patients: stroke, brain dysfunction
(traumatic and non-traumatic), spinal cord dysfunction (traumatic and nontraumatic) and major multiple trauma. The expected results are
improvement of accessibility, continuity, quality of care as well as the proper
payment and information of activities, unit costs. Fifty five hospitals in five
provinces were recruited voluntarily to develop rehabilitation services both
facility-based and home-based care, referral system, structure, payment,
information system etc. Three development steps were set up as follows:
1) setting the new desirable system, 2) implementation of the new system
(according to context of each province) and 3) evaluation. The effectiveness
will be assessed through functional status and quality of life gained
compared to set target. The efficiency studies consist of cost per patient,
cost per DRG and cost recovery. Barthel Index (assessment of 10 functions:
feeding, transfer, grooming, toilet use, bathing, mobility, stairs climbing,
dressing, bowels, and bladder) and EQ5D (Assessment of quality of life in 5
dimensions including: mobility, self-care, usual activities, pain/discomfort
and anxiety/depression) will be used for functional assessment. The study
will go on for 18 months.
O7
Health care efficiency and climate change implications linked to
reproductive health in developing countries
David Baguma*, Jamal Hisham Hashim, Syed Mohamed Aljunid
Kuala Lumpur Malaysia
E-mail: baguma.david@yahoo.com

Page 6 of 10
Introduction: Health care services for pregnant women and children are
partially influenced by externalities such as climate change and
environmental hazard health risks i.e., the vulnerabilities confounded
within food insecurity and extreme weather events (floods) in drought
prone geographical regions. The unhygienic conditions due to lack of
adequate safe water and sanitation also compromised their health status.
In this paper, we further attempt to examine the possible implication of
climate change hazards on pregnant women and children exploring
efficiencies within health care systems.
Materials and methods: The data on population growth rates between
1650 and 2008, the reproductive health literature (use of contraceptive and
pills between 1993 and 2007), and climate change effects (temperature
variation and changes in diseases reported such as diarrhoea or vectorborne diseases transmitted by malaria and dengue) were collected on
countries: Bangladesh, Malaysia and Uganda. The data were reviewed and
descriptive analyses used to give an overview on the possible implications
of climate change to health care efficiency in South Asia and Sub-Saharan
Africa.
Results and discussion: The findings show that temperature variations are
associated with increase in numbers of mosquitoes, which could link malaria
related deaths to changes in climate scenarios. This studys findings also
indicate that efficiency in health care is affected by housing condition,
cultural beliefs, levels of income and education, and water and sanitation.
The number of diarrhoea related cases for children (<5 years) increased with
periods when rainfall was high, which links climate change to water-borne
diseases. This study supports findings which found that natural immunity in
women is suppressed especially during pregnancy making them
vulnerability to water-borne illness (such as caused by unhygienic water
sources), which is exacerbated by inefficient health care systems and
services.
Conclusion: Health care efficiency could be enhanced by improvements in
capacity building e.g., training in antenatal and paediatric care, or adoption
of technologies that improve information flow in health facilities e.g.,
Casemix systems for documentation. To improve health care efficiency, we
also recommend emphasis on effective interventions for the prevention and
control of diseases at all level of health care structures (i.e., environmental
health services), foster climate change adaptation and mitigation measures.
current reimbursement system and to find out the impact of the newly
developed tariff. At the end of this study, the researcher will come up
with some recommendations on the use of Casemix system for JKA
program.
Conclusion: This study will provide valuable input to enhance the
implementation of JKA in Aceh. The outcome of the study will develop
new Casemix based tariff which has positive impact on the sustainability
of JKA program.
O8
Development of package payment based on UNU-CBGs Casemix
system for provider payment in Aceh Health Insurance, Indonesia
Irwan Saputra*, Syed Mohamed Aljunid, Amrizal Muhammad Nur
E-mail: iwan_bulba@yahoo.com
Background: The Aceh Health Insurance (JKA) has been established since
June 1, 2010. Presently, the provincial Government of Aceh faces difficulty in
getting adequate budget to fund JKA program that tends to increase every
year. In the year 2010, the second year of JKA implementation, the
government was only able to allocate Rp. 382 billion from the total
requirement of Rp. 482 billion. The figure will possibly continue to increase
next year because of the increase in the overall hospital tariff of adjustments
where there was an increase over 50%. In addition, there were complaints
that quality of care is not optimum. The fee for service reimbursement
system in JKA is one of the reasons for increase in cost of JKA. The main
purposes of this study are to develop and implement the Casemix system as
a provider payment mechanism and to assess its feasibilities to improve the
performance of JKA program.
Method: Qualitative approach using in-depth interview will be conducted
in this research to evaluate the current reimbursement system of JKA. Major
stakeholders in the JKA program such as governor, representative council,
and head of health directors of hospital will be sampled in this study.
Quantitative methods will be applied to collect the data for Casemix
implementation from selected hospitals on the data of disease coding and
hospital costing. Costing data will be analyzed using Clinical Cost Modeling
(CCM) software, whereas the coding data use UNU-CBGs grouper software
to develop new hospital tariff for JKA.
Result: The expected result of this research is on the evaluation of JKA
implementation. Simulation exercises will be used to compare with the
O9
The impact of Casemix system on quality of patient care in a Class B
hospital in west Sumatera Province, Indonesia
Kamal Kasra1*, Amrizal Muhammad Nur2, Syed Mohamed Aljunid2
1
Andalas University of Padang, West Sumatera, Indonesia; 2United Nations
University International Institute for Global Health, Kuala Lumpur, Malaysia
E-mail: kamalkasra@yahoo.com
Background: Health spending in Indonesia is on the increase every year
due to a number of factors including change in pattern of diseases towards
chronic and non-communicable conditions, priority on curative care rather
than preventive services, use of new technology in health services and use
of fee-for-service for provider payment. Raise in health care cost can have
negative impact on accessibility of health service by the poor communities.
In Indonesia, the Ministry of Health has launched a special program to
ensure that the poor have access to health care services. One of the most
important programs is JAMKESMAS, which is a special health financing
scheme for the poor funded by taxation. The implementation of Casemix in
Indonesia is based on a special law (Undang-undang No.40) and Minister of
Health decree (SK Menkes No. 1663/MENKES/SK/XII/2005). Casemix was
implemented as a pilot project involving 14 hospitals in 2005. However in
2008, the use of Casemix was extended to cover all hospitals in Indonesia.
Hospitals are reimbursed on locally customized Casemix system called INACBG, which is based on UNU-CBG case-mix grouper. In the first phase of
Casemix implementation, the system was used to develop hospital tariff for
prospective payment with the objective of enhancing service efficiency.
However it is widely known that Casemix system is also a powerful tool to
enhance quality of care. A number of challenges were identified in the early
part of case-mix implementation in Indonesia. These include lack of basic
data for Casemix, poor documentation of diagnosis and procedures, and
ineligible handwriting of doctors in the medical records. Presently, there is
no study carried out in Indonesia to assess the impact of case-mix system
implementation on quality of patient care.
Objective: The aim of the study is to evaluate the impact of Casemix
implementation on quality of patient care in one class B hospital in West
Sumatera, Indonesia.
Method: Both qualitative and quantitative methods will be used in this
study. The respondents in the study are staff working the hospitals who are
directly involved with the JAMKESMAS and case-mix system. This includes
doctors, nurses, medical coders and financial officers. Qualitative data will be
gathered through in-depth interview with selected respondents. Quantitative
data will be collected using self-administrated questionnaires and service
observation checklist.
Conclusion: It is hope that this study will shed lights on the role of
Casemix system in improving quality of patient care.
O10
Using alternative programming algorithms and techniques for
optimizing performance of the Casemix software
H Reeza1*, A Zafar1, AJ Hamzah1, Syed Aljunid2
1
International Training Centre for Casemix and Clinical Coding (ITCC), UKM
Medical Centre, Kuala Lumpur, Malaysia; 2United Nations UniversityInternational Institute for Global Health, Kuala Lumpur, Malaysia
E-mail: hasrulreeza@gmail.com
Introduction: Casemix system is a patient classification system that
classifies patients into predefined groups based on the patient level data.
Because of the immense variation of the individual patient level data it is
very tedious to do this Casemix group allocation manually, instead Casemix

Page 7 of 10
classification software with a predefined logic is used. UNU-IIGH has

developed Casemix logic, and an application for easy usage by end users.
As part of continuous quality improvement, it was to upgrade the Casemix
software for improved data processing.
Objective: To create an appropriate algorithm and utilize Java programming technique for optimizing Casemix software.
Methodology: Casemix logic requires lots of data input in order to classify
for each of its class. To begin with, the current Casemix logic algorithm will
be broken down and analyzed. Due to multiple matching process, the
system should be refined and recreated to an efficient algorithm such as
binary search method to replace the current linear search method which is
slow in searching, matching method and database access. The developed
prototype will be tested for the efficient data processing using a 1 Million
patient and the performance compared with the earlier version. The
efficiency test is expected show the increased performance of new
alternative programming algorithm and techniques approach for optimizing
the system.
Results: The current system in use is using linear search method which has
time complexity of O(n) to do the matching process. By implementing
binary search method, in the proposed solution, the time complexity is
O (log n) which is proven to be faster than linear search method. The new
programming algorithm and techniques used in the new prototype Casemix
software are expected to increase the speed of matching process and
accessing database. It is estimated that it will increase the search process
15% quicker than previous Casemix software. This enhanced performance of
the newly developed prototype Casemix software will be used in future
development.
available for all healthcare centers as it is web enabled. By deploying such

software in different healthcare centers in rural India, we can increase the
usage of EHRs thereby increasing the efficiency of Healthcare Delivery and
reducing the cost of healthcare.
POSTER PRESENTATIONS
P1
Web-based electronic health record system
Aniruddha Patil*, Pranav Manikpure, Shankar Kokare, Makarand Nale,
MS Chaudhari
Dept. of Computer Eng., SIT, Pune University, Lonavala 410401, India
E-mail: aniruddha.111@gmail.com
BMC Health Services Research 2012, 12(Suppl 1):P1
Introduction: The use of healthcare delivery systems is very limited.
Primarily in India public sector hospitals does not use any system for
managing their health records to provide continued care to patient. The
central and state governments are responsible for the provision of primary
healthcare in the country. A spending of 1% of the GDP (effectively about
Rs 1050 per capita) on public health is not only dismally low but most of
the expenditure is on staff salaries leaving little or nothing for facilities,
drugs and other consumables.
Methodology: During the registration process patients previous medical
history, the data to be stored is divided in two sections as administrative and
clinical content which is as follows: the administrative content includes: (1)
identification patients complete name, medical record number, address,
mothers maiden name; (2) lifestyle indicators education level, profession,
allergies, chronic illnesses, marital status, food, preferences, smoking and
alcohol consumption. The clinical content includes: (1) symptoms, physical
examination results; (2) drugs prescribed, inpatient history; (3) lab reports pathology/radiology/ECG/EEG/EMG.
Results: The EHR system: (1) must be capable of containing information on:
healthcare processes, activities, medical problem, healthcare requests,
healthcare characteristics, resources, users and authorization. (2) Should allow
for the recording of all data on the patient history, physical examination,
diagnostic test, and therapeutic interventions to support patient care.
(3) Should allow for pre-birth and post-death entries. (4) Should allow for the
recording of interpretations, observations, decisions request for further
investigations, treatment or discharge. (5) Must be able to reflect that a
patient may have concurrent problems. (6) Should support the use of
technologies, decision support and management plans.
Conclusion: The software we are going to design definitely more helpful to
the doctor and patient. The complexity of the paper work will be reduced
and provide the future health support to the patient and the country.
Benefit of the software is: (1) healthcare awareness of patient increases,
(2) demographic information will be available for planning better healthcare
delivery, (3) addresses the issue of patient mobility as patient information is
P2
Catastrophic Health Expenditure and its influencing factors in Malaysia
Sharifa Ezat WP1*, Azimatun Noor Aizuddin1, Zakiah Zainuddin1,
Mohd Rizal Abd Manaf1, Syed Aljunid2
1
Department of Community Health, UKM Medical Center, Kuala Lumpur,
Malaysia; 2United Nations University International Institute for Global Health,
E-mail: sh_ezat@yahoo.com
Catastrophic Health Expenditure (CHE) is a term used for any expenditure
for health that can pose as threat towards households financial capacity
and capability in order to maintain its subsistence needs. The World Health
Organization in 2005, proposed that health expenditure be viewed as
catastrophic when it is equal or exceed 40% of a households nonsubsistence income. Surveys done in 89 countries, covering 89% of the
worlds population suggest that annually 150 million people suffer from
CHE. The ever rising healthcare cost and anticipating the nature of illhealth against extraordinary expenditure on health may lead the
individual/household into CHE and poverty. In Malaysia, estimation by the
Malaysia National Health Accounts, the per capita out of pocket (OOP)
health expenditure is increasing, however we are highly subsidized by the
government thus protecting at risk populations. With the current
healthcare reform thus ensuing the proposed National Health.
Insurance and less tax financed subsidized health care, the risk of CHE is
higher. In 2007, Malaysias total health expenditure (THE) was 4.4% of GDP;
equivalent to $307 per capita and OOP making up 40.7% of THE. OOP
financing exacerbate poverty and is regressive. This study plans on
determining current actual and projected CHE level and its influencing
factors in Malaysia. This will encourage efforts to provide higher degree of
protection for low income groups against the economic impact of illness
without jeopardizing the quality of services and equity of health financing.
It is hoped that once the actual prevalence of CHE and its monetary level
attained, these will give a strategic policy application, to reduce inequality
by ensuring better access to health for all and mitigating the risk factors to
the high risk populations.
P3
Economic evaluation of monoclonal antibody in the management of
colorectal cancer in Malaysia
MS Natrah1*, Sharifa Ezat WP1, MA Syed2, Mohd AM Rizal1, S Saperi1, S Ismail1,
I Fuad1, Muhd MA Azrif1
1
National University of Malaysia, Cheras, Kuala Lumpur, Malaysia; 2United
Nations University International Institute for Global Health, Kuala Lumpur,
Malaysia
E-mail: chenat77@yahoo.com
Introduction: The introduction of monoclonal antibody in the management
of Colorectal Cancer (CRC) in the rapidly rising healthcare cost environment
prompt a proper evaluation of its cost effectiveness especially to the local
setting. The rising incidence of CRC in Malaysia also justifies a detailed
evaluation on its economic impact. This study aims to determine the cost of
CRC management and to compare the cost effectiveness of monoclonal
antibody with conventional chemotherapy in the management of CRC.
Methods: This economic evaluation study was performed from the societal
perspective. It involves collecting resource utilization data based on clinical
pathway of colorectal cancer management. Cost calculated included cost of
drugs, human resources, administrative, investigations as well as capital cost.
Direct and indirect patients cost were also calculated based on interview
with CRC patients. CRC patients quality of life were measured using EORTC
QLQ-C30 questionnaire and effectiveness estimates for monoclonal antibody
(Cetuximab and Bevacizumab) treatment were modeled from study
respondents based on references from other studies. One way sensitivity
analysis was used to determine the robustness of the result.

Result: A total of 160 respondents were involved in the study with the
mean age of 58.47 (SD 12.04) years. The average cost of treating a case of
colorectal cancer is RM 22,833.44 (RM 18,818.53 - RM 26,848.35). Cost of
CRC management increased with increasing stage of the disease (Kruskal
Wallis, X 2 = 106, p < 0.001). Incremental cost per life years gained is
RM 118,366.37 for Cetuximab and RM 61,584.68 for Bevacizumab.
Incremental cost per quality adjusted life years gained for Cetuximab is RM
67,063.83 and RM 34,892.47 for Bevacizumab. Although both types of
monoclonal antibody are considered cost effective (based on WHO
guideline of less than 3 times of GDP), Bevacizumab is considered more
cost effective than Cetuximab. Sensitivity analysis shows that, cost
effectiveness was sensitive to the percentage of late stage of CRC.
Conclusion: Monoclonal antibody especially Bevacizumab is more cost
effective in the management of late stage of CRC. Therefore it should be
considered to be used in the CRC as a combination with the current
chemotherapy treatment for CRC. The country should invest to the
administration of monoclonal antibody to CRC treatment.
P4
A comparative study of cost and quality of life among Skeletal
Related Events (SRE) and non-SRE among breast and prostate
cancer patients in Malaysia
Noraziani Khamis1*, Sharifa Ezat WP1, Aljunid Syed2, Zafar Ahmed1
1
National University of Malaysia, Cheras, Kuala Lumpur, Malaysia;
2
United Nations University International Institute for Global Health,
E-mail: noraziani17@yahoo.com
Background: The human skeleton is the most common organ to be
affected by metastatic cancer (skeletal or bone metastases). The prevalence
of skeletal disease is greatest in breast and prostate carcinoma. Bone
metastases lesions weaken bone structure, causing a range of symptoms and
complications. Sufferers of breast and prostate cancers may develop Skeletal
related events (SRE). These SRE are defined as pain that require palliative
radiotherapy or surgery to bone, hypercalcaemia, pathologic fractures, spinal
cord compression and bone marrow failure. These complications contribute
to a decline in patients HRQOL (health related quality of life). However,
information on treatment costs of breast and prostate cancers and
multidimensional assessments of QOL are limited. Thus this study aim to
obtain both cost and QOL of breast and prostate cancers patients and to
determine their relationship with the patients sociodemograhic profiles (age,
ethnicity, income) and disease profile (tumour types, cancer stages and SRE
status).
Objective: To determine the health care cost and QOL of breast and
prostate cancer patients in Malaysia. The association of risk factors
(sociodemographic and diseases profiles including SRE status) and cost
and QOL will later be determined through statistical analysis.
Methodology: This will be a societal approach, cost evaluation technique
through a cross sectional study for a projected period of 9 months. Both
qualitative and quantitative approach to estimate the health care cost of
provider and patients cost through microcosting questionnaire method.
Patients QOL will be using the locally validated EORTC-QLC-C30
questionnaire. Selected patients from oncologic and surgical wards,
outpatients specialists clinics will be taken as respondents. Outcomes of
study will include cost to treat a case of SRE and projected countrys
burden of SRE from both cancer. Other outcomes will be compared
between SRE and non-SRE through measurements of cost per QALYs;
cost per life years saved (LYS) and cost per deaths averted. Associated
risk factors will be measured by bivariate and multivariate analyses with
power of study of 80% and p value of 0.05.
Expected result: The cost of treatment among prostate and breast
cancer patient of lower disease compared to those of higher stages,
positive bone metastasis and SRE positive. The QOL will also be expected
to be higher among these groups. By similar disease stages for each
cancer types, the QOL and costs are expected to be similar.
Conclusion: This information will provide the cost burden of breast and
prostate cancers for the country and will be used for strategic planning
for the country. Patients with risk of lower QOL will also be identified for
better risk assessment during cancer managements.
Page 8 of 10
P5
Predicting patients arrival to the Emergency Department UKMMC
Noriza Majid1*, Sharifa Ezat WP2, Saperi Sulong2, Zuraidah Che Man3
1
School of Mathematical Sciences, Faculty of Science and Technology, UKM,
Selangor, Malaysia; 2Department of Community Health, Faculty of Medical,
UKM, Kuala Lumpur, Malaysia; 3Department of Accident and Emergency,
Faculty of Medical, UKM, Kuala Lumpur, Malaysia
E-mail: nm@ukm.my
Objectives: To model and predict daily patients arrival to the Emergency
Department (ED) based on preceding year data using parametric fitting
methods.
Methods: Daily patients arrival starting from the year of 2005 to 2009 to
the ED of UKM Medical Centre was studied. The patients arrival patterns
were described. Poisson and Negative Binomial models that are
commonly used in modeling frequency were selected to represent the
number of patient seeking treatment at ED per day. Maximum likelihood
method is used in estimating the parameters for both distributions.
Models accuracy were assessed by comparing the predicted arrivals that
obtained from the proposed models and observed arrival using goodness
of fit test.
Results: The best model to predict the patients arrival to the ED is based
on the results of p-p plots, the Schwarz-Bayesian criteria, the maximum
likelihood function and chi-squared test. Results from the analysis shows
that for five consecutive years, the patients arrival to the ED at UKM
Medical Centre follows the Negative Binomial distribution with an
average of 192 patients a day.
Conclusion: This study confirms that the number of arrival of the patients
explains the daily demand for the A&E services. It is very important for the
department to understand the pattern of patients arrival in order to help
the hospital strategize and optimize its resources.
P6
The cost of treating an acute ischaemic stroke event and follow-up
at a teaching hospital in Malaysia: a Casemix costing analysis
FAA Aznida1,2*, Nor MN Azlin1,2, MN Amrizal1, S Saperi2, SM Aljunid1
1
Lumpur, Malaysia; 2University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
E-mail: draznida@ppukm.ukm.my
Introduction: Stroke is a continuum spectrum of complications related to
the cerebrovascular event. Economic evaluation usually estimates costs
incurred during acute management phase. Costs for managing post
stroke patients at Specialist clinic setting and outpatient rehabilitation are
of interest for developing countries which largely provide this type of
service. We aim to determine costs for treating acute ischaemic stroke
and subsequent follow-up after discharge at a tertiary teaching hospital.
Methods: Cost analysis was done via top down costing and from the
healthcare providers perspective. Casemix database was used to collect
data on consecutive admissions for acute stroke events based on severity
for period of January to December 2010. Patients follow-up visits to the
Specialists Outpatient clinics and stroke rehabilitation were traced through
HIS to facilitate cost aggregation, as this is not generated by the Casemix
system. MY DRG codes were referred to in estimating cost at all stages of
stroke care. Codes for minor and moderate stroke were combined to
represent minor stroke category.
Results: The average length of stay in hospital for acute major stroke was
9.8 (SD 7.1) days while for minor stroke 3.6 (SD 1.6) days. In the 3 month
period after the acute event, an average of 2 visits were made to the
Specialist outpatient clinic for both the minor and major stroke types. For
outpatient rehabilitation, patients attended an average of 10 and
15 sessions for minor and major stroke severity respectively over a sixmonth period. The cost for treating a patient with acute major stroke per
admission was MYR 9000 (SD 6569). For a minor stroke the cost was MYR
3353 (SD 1444). In the Outpatient setting, the cost per visit to Specialist
clinic was RM103 and the cost of rehabilitation was RM43 per patient per
session irrespective of stroke severity.

Page 9 of 10
Conclusion: The cost for treating an acute ischaemic stroke event is

substantial in Malaysia. Major stroke consumes three times as much
medical resource than a minor stroke. Primary and secondary prevention
measures should be strengthened to reduce stroke prevalence and
incidence in view of substantial treatment costs. Reasons for poor
utilization of post-stroke treatment warrant further studies.
and 2010). Annual reports from the dental subsystem of the government
Health Information Management System (HIMS) provided information on
oral health care delivery for years 2006-2010. These reports were a
summary of aggregated data and did not allow for further analysis other
than reporting absolute numbers and frequency distributions.
Results: There was a slight decline of periodontal disease prevalence
between 1990 (92.8%) to 2000 (90.2%) but a sharp rise was observed in
the 2010 survey (96.7%). In terms of severity, there was increase in the
proportion of subjects demonstrating periodontal destruction in the 2010
survey after showing improvements in the 2000 survey. Parallel to this
observation, percentage of subjects not requiring periodontal treatment
(TN0) increased from 1990 to 2000, only to drop in 2010. An increase in
patients attendance was observed alongside a growing uptake of
periodontal-related procedures (62.2% in 2006 to 73.6% in 2010) as
compared to non-periodontics treatment. However, only about 10% of
periodontics procedures were surgeries with the most common being flap
surgery. Counselling was the most common non-surgical procedure
observed. The highest number of non-periodontics dental procedures
done was restorations while the least was fixed prosthodontics.
Conclusion: The rising periodontal treatment needs in the population do
not seem to have been met. In spite of the upward trend of clinic
attendance, the mix and distribution of treatment provided did not reflect
the increasing needs for complex periodontal treatment. There is a need
for a more efficient delivery of public health promotion strategies to meet
oral health needs of the population.
P7
Peoples expectations from healthcare providers a Turkish perspective
Saad A Ali Jadoo Alazawi1*, Syed Aljunid1, Seher Nur Sulkus2, Zafar Ahmed3,
Sharifa Ezat WP4
1
United Nation University International Institute for Global Health, Kuala
Lumpur, Malaysia; 2Department of Econometrics, Economics and
Management Sciences Faculty, Gazi University, Ankara, Turkey;
3
International Centre for Casemix and Clinical Coding, UKMMC,Kuala Lumpur,
Malaysia; 4Department of Community Health, Faculty of Medicine, National
University of Malaysia, Kuala Lumpur, Malaysia
E-mail: herblist2020@yahoo.com
Background: There is high expectation from the population on part of
the healthcare providers. These include; skillful and timely medication
administration; and knowledge, honesty, listening skills, availability and
professional attitude. The aim of this paper is to evaluate the expectation
of population with regards to the healthcare providers in Turkey.
Methodology: A cross sectional study in Turkey, including both rural and
urban population, carried out from October 2011 till January 2012. A total of
540 heads of household were selected using multi stage random sampling.
Data was collected using structured self-administered questionnaire. The
tools used was modified 16-item Quality of Care Through the Patients Eyes
(QUOTE) questionnaire. QUOTE questionnaire measures communication/
accessibility, organizational skills and professional skills. The response rate
was (77.1%) and data was analyzed by using SPSS version 16.0.
Results: All aspects measured using QUOTE questionnaire were found to
be important or extremely important by the respondent, but with varying
degrees of priority. Quality aspects related to the professional skills of
physicians came first followed by communication or accessibility and last
but not the least are the organizational skills of health care providers.
Conclusion: This study explored the Turkish people priorities and
expectations regarding healthcare providers. Level of expectation varies
across the population. This may reflect the need to understand peoples
expectations before providing the services to avoid complaints that may
occur after the services have been rendered.
P8
Periodontal status and provision of periodontal services in Malaysia:
are we meeting population needs?
Tuti N Mohd-Dom1,2*, Syed M Aljunid1,3, Rizal A Manaf4, Khairiyah A Muttalib5,
Ahmad SM Asari5
1
United Nations University International Institute for Global Health, Universiti
Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, 56000 Bandar Tun
Razak, Malaysia; 2Department of Dental Public Health, Faculty of Dentistry,
Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia; 3International
Training Centre for Casemix and Coding, Universiti Kebangsaan Malaysia,
Kuala Lumpur, Malaysia; 4Department of Community Health, Universiti
Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia; 5Oral Health
Division, Ministry of Health, Putrajaya, Malaysia
E-mail: tutinin@gmail.com
Background: The absence of published literature on periodontal
treatment needs and services in developing countries has undermined the
significance of periodontal disease burden and impacts on patients and
healthcare systems. This study analyses periodontal status and population
treatment needs of Malaysians as well as patterns of periodontal services
provided at public dental clinics.
Methods: A retrospective approach to analysis of secondary data was
employed. Data for population treatment needs were extracted from
three decennial national oral health surveys for adults (1990, 2000
P9
Feasibility of implementing DRG system for inpatient on PT Askes
providers
Novianti Br Gultom*, MM APT
PT Askes (Persero), Indonesia
E-mail: noviask03@yahoo.co.id
PT Askes (Persero) uses a combination of fee-for-service (FFS) and package
tariff as a provider payment mechanism. Based Wouters, Annemarie et al
(1999), FFS system has a high financial risk for payor. The objectives of this
paper are to give a preliminary comparison between INA-CBGs (which is
Indoesian DRG) and Askes tariff (MoH Act number: 416/Menkes/Per/II/
2011), to estimate financial risks associated with the adequacy of premium
if using INA-CBGs and to gain recommendation for Askes in a preparation
as an Organizing Bodies of Social Security in 2014. These three objectives
are answered by calculating 10 most expensive inpatient diagnoses of
Askes 2011 and comparing the cost and Length Of Stay (LOS) of both
tariff. Askes tariff doesnt have severity level, whereas INA-CBGs has three
severity levels with five different accommodation classes (III, II, I, VIP and
VVIP). The study uses variety of the lowest cost (III accommodation,
severity level i), the moderate cost (II accommodation, severity level ii) and
the high cost (I accommodation, severity level iii).The results showed that
(1) by using III accommodation with a severity level i: Askes tariff higher
than INA-CBGs with financial risk decrease to 73%, (2) by using II
accommodation with a severity level ii: Askes tariff still higher than INACBGs with financial risk about 143%, (3) by using I accommodation with a
severity level iii: Askes tariff lower than INA-CBGs with higher financial risk,
approximately 234%. Overall, Askes LOS is controllable compare to the
ALOS of INA-CBGs. This study recommends the alternative provider
payment mechanism for Askes. If Askes uses INA-CBGs with III
accommodation it will minimize the financial risk. Whereas if Askes uses II
and I accommodation, then the adequacy of the existing premium must
be taken into account, i.e. by the estimation of financial risk. As a leading
social health insurance company in Indonesia, which will have a big
number of member in 2014, PT Askes has to train the staffs about DRG
(costing, coding, collecting data, auditing tool, grouping, IT, etc). On
considering the complexity of the DRG scheme, rather to make the new
one, it is a good beginning to start with the existing DRG which is INACBGs from MoH, and then gradually re-calculate the cost weight and base
rate and update it yearly. Nevertheless, the adequacy of the existing
premium must be taken into account. Hopefully, the health care costs
for the whole population of Indonesia will be more controllable in the
future.

P10
Estimating cost of in-patient medical care for stroke using
Casemix data
Nor Azlin Mohd Nordin1*, Amrizal Muhamad Nur1, Saperi Sulong2, Syed Aljunid1,2
1
Lumpur, Malaysia; 2International Casemix & Clinical Coding Centre, Universiti
Kebangsaan Malaysia, Kuala Lumpur, Malaysia
E-mail: azlin8@yahoo.com
Background: There is a lack of data on financial impact of stroke despite
the increase in hospital admissions due to this disease in Malaysia. This
study aimed to estimate the cost of medical care for patients hospitalised
in a main teaching hospital following a stroke.
Method: A retrospective analysis was conducted using data of stroke
patients maintained by the Casemix Unit of Universiti Kebangsaan Malaysia
Medical Centre. Variables studied were the patients demography, clinical
profiles and length of hospital stay. Cost evaluation was carried out from the
hospital perspective using Top-down costing approach. Data was analysed
with the use of SPSS version 19.
Results: Data of 748 stroke patients were retrieved for analysis. The average
length of hospital stay was 6.4 (SD: 3.1) days. The mean cost of medical care
was RM 3696.40 (SD: 1842.10) per stroke patient per admission. Human
resources made up the highest cost component (RM 1343.90, SD: 669.8) or
36% of the total cost of care, followed by medications (RM 867.30, SD:
432.40) and laboratory tests (RM 337.90, SD: 168.40). The cost increased by
15% when patient suffered from moderately severe stroke and further
increased by 52% in the highest level of severity compared to mild stroke
(p < 0.05). No significant differences were found when comparing costs
between the sub-groups of age, gender and stroke sub-types.
Conclusion: There is a substantial cost involved in the care of in-patient
stroke in this study. Further research involving other health care settings are
required to better estimate the financial impact of stroke to this country.
P11
Cost of Magnetic Resonance Imaging (MRI) and Computed
Tomography (CT) scan in UKMMC
Roszita Ibrahim2*, Sadon Samian2, MZ Mazli2, MN Amrizal1,
Syed Mohamed Aljunid1
1
United Nations University- International Institute of Global Health, Kuala
Lumpur, Malaysia; 2Department of Radiology, UKMMC, Kuala Lumpur, Malaysia
E-mail: roszita@ppukm.ukm.my
Introduction: Department of Radiology, Universiti Kebangsaan Malaysia
Medical Centre (UKMMC), is one of the intermediate cost centres for ward
and polyclinic. Magnetic Resonance Imaging (MRI) and Computed
Tomography (CT) scan are among the radiology investigations that consume
high amount of resources. However, the actual cost of these procedures has
never been properly imputed before. The charge for these procedures in
UKMMC ranges from RM 550 - RM 800 and RM 100 - RM 450 for MRI and CT
scan, respectively. These charges are lower as compared to private sectors
and other teaching hospitals in Malaysia. Therefore, the aim of this study is
to analyze the cost of MRI and CT scan procedures in UKMMC including the
component cost that are involved in these procedures.
Method: A cross sectional study was conducted from January to March
2012 among radiographer in UKMMC. Activity Base Costing (ABC) method
was used to analyze the cost of procedures involving Magnetic Resonance
Imaging (MRI) and Computed Tomography (CT) scan. Data was collected
using a micro costing form with six component costs which are; 1) staff
salary 2) consumables 3) equipments 4) reagents 5) administrative and
6) maintenance of equipment used. The results were analyzed using SPSS
version 20.0.
Results: The cost of MRI procedures with contrast and without contrast per
patient was RM 1118.00 and RM 975.00, respectively. Amongst six component
costs, equipment was the highest in both with contrast (RM 854.37; 76.4%)
and without contrast (RM 854.37; 87.6%) of MRI procedure. While, cost of
maintenance (RM 61.51; 6.3%), and staff salary (RM 38.60; 4%) was the lowest
in MRI procedures with and without contrast, respectively. For CT scan
procedures per patient with contrast for head, orbit and temporal bone was
RM 286.00 with the highest component cost was equipment (RM 139.48;
Page 10 of 10
48.8%) and staff salary (RM 35.70; 2.5%) was the lowest. In addition, CT scan
procedures per patient with contrast for neck was RM 356.00 with the highest
component was equipment (RM 139.48; 39.2%) and staff salary (RM 35.70;
10%) was the lowest. While, the cost of CT scan procedures per patient with
contrast for thorax and abdomen was RM 402.00 with the highest
component cost was reagent (RM 146.90; 36.5%) and staff salary (RM 35.70;
8.9%) was the lowest. The cost of CT scan procedures per patient without
contrast was RM 216.00 with the highest component cost was equipment
(RM 139.48; 64.6%) and staff salary (RM 33.15; 15.3%) was the lowest.
Conclusions: Our data indicate that the cost for the Magnetic Resonance
Imaging (MRI) procedure of with and without contrast was RM 1118.00 and
RM 975.00, respectively. While, the cost of CT scan procedure with and
without contrast was RM 402.00 and RM 216.00, respectively. Cost of
equipment was the highest component, thus this finding will contribute to
an efficient hospital management in terms of financial and resource used.
P12
Role of data mining in establishing strategic policies for the efficient
management of healthcare system a case study from Washington
DC area using retrospective discharge data
Harleen Kaur1*, Ritu Chauhan2, Zafar Ahmed3
1
United Nations University International Institute of Global Health (UNU-IIGH),
Kuala Lumpur, Malaysia; 2Hamdard University, New Delhi, India; 3International
Case Mix and Clinical Coding Centre, UKM Medical Centre, Faculty of Medicine,
University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
E-mail: harleen.k@unu.edu
Background: Many physicians are perplexed with an acute increase in
the rate of pregnancies and live birth, and a decrease rate of abortions
among the women in the Washington DC area. Healthcare managers are
analyzing the admission and discharge data to understand this trend.
There are many factors such as marital status, age, income, health
problems during pregnancy, insurance coverage and other treatment
expenses, existence of psychological and emotional problems, patients
experience while stay at hospital, and most importantly the increasing
cost of abortion that can lead to this sudden increase in rate of live birth
and subsequent decrease in the abortion rate in Washington DC area.
Objective: The main objective of this study is to study the factors that
lead to this increase in the rate of pregnancies and live birth, and
decrease in the rate of abortion in the Washington DC area.
Methodology: A qualitative approach is used to evaluate and determine
the factors that have lead to this increased rate of pregnancies and live
child births in Washington, DC area. The Data mining, clustering and
statistical techniques were used to evaluate the Casemix datasets to
understand the causes increased rate of pregnancies, live birth and reduce
rate of abortions in Washington, DC area. Eight hospitals in Washington DC
area were randomly selected and included in this study. The Casemix data
set of the patient giving live birth at these eight hospitals were abstracted
and studied from January to December 1992. The associated patterns
leading to the increased rate of live birth and decrease rate of abortions
are discovered for further analysis with K means clustering and other
statistical techniques.
Results: The cost of abortion is the main factor, among the positive
factors, that has lead to an increase rate of live births among the cases
studied. The unmarried women who cannot afford the cost of abortion
were ranked among the highest to continue with the pregnancy whereas
the rate of live birth was lowest among the married womens.
Conclusion: This type of information will provide the basis for the proper
strategic planning and can help establish policies to provide assistance to the
unmarried womens for abortions or a different policys to remove the cost of
burden for abortion. The study may help to develop policies that can lead to
a decrease in the rate of live births due to increase in cost of abortion.
Cite abstracts in this supplement using the relevant abstract number,

e.g.: Kaur et al.: Role of data mining in establishing strategic policies for
the efficient management of healthcare system a case study from
Washington DC area using retrospective discharge data. BMC Health
Services Research 2012, 12(Suppl 1):P12

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BMC Health Services Research 2012, Volume 12 Suppl 1

Proceedings of the 6th International Casemix

INVITED SPEAKER PRESENTATIONS

3) ensure that a classification is available that can be used without

BMC Health Services Research 2012, Volume 12 Suppl 1

developments are needed to document knowledge generation related to

BMC Health Services Research 2012, Volume 12 Suppl 1

cost of hospitalization in specific departments, costs per weighted case

considers rehabilitation and medical service highly in their hierarchical

BMC Health Services Research 2012, Volume 12 Suppl 1

Introduction: Hospital cost analysis is an essential tool relating the inputs

impact of DRGs on efficiency mostly focused on technical efficiency or

BMC Health Services Research 2012, Volume 12 Suppl 1

was to evaluate the effectiveness of Introduction to UNU-Casemix Grouper &

BMC Health Services Research 2012, Volume 12 Suppl 1

BMC Health Services Research 2012, Volume 12 Suppl 1

classification software with a predefined logic is used. UNU-IIGH has

available for all healthcare centers as it is web enabled. By deploying such

BMC Health Services Research 2012, Volume 12 Suppl 1

BMC Health Services Research 2012, Volume 12 Suppl 1

Conclusion: The cost for treating an acute ischaemic stroke event is

BMC Health Services Research 2012, Volume 12 Suppl 1

Cite abstracts in this supplement using the relevant abstract number,

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