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Measuring Severity of Illness:

Comparisons Across Institutions


SUSAN DADAKIS HORN, PHD

Abstract: Conventional methods for classifying


patients with respect to utilization of health care
resources are based almost exclusively on diagnostic
criteria. We review a new severity of illness index
which is generic to most medical and surgical conditions in a hospital, and which has been found to
produce subgroups of patients more homogeneous
with respect to hospital resource use (as assessed by
total charges, length of stay, routine charges, and

Introduction
As medical costs continue to rise alarmingly, government and other third party payors have sought ways to
control them. A fundamental requirement for the control of
inpatient hospital costs is a means of classifying patients
admitted to a hospital by a standard which accurately
reflects patients' use of health care resources. The conventional approach to this requirement has been classification of
patients into diagnosis-related groups (DRGs) such as acute
myocardial infarction (AMI), congestive heart failure (CHF)
with and without a surgical procedure, etc.'
Such conventional classification systems, which are
based primarily on diagnostic criteria, fail to take into
account the great range of severity of illness that exists
within each diagnostic category, hence they may not accurately reflect a patient's use of expensive care modalities.
This problem might be expected to be particularly troublesome when a diagnosis-based classification system is used to
compare outputs from different hospitals. For example, an
academic teaching hospital in a large city may be expected to

laboratory charges) than diagnostic-related groups,


staging, and generalized patient management paths.

We use the severity of illness groups to compare total

charges and length of stay across hospitals. We find


that charges and length of stay in an academic teaching
hospital are similar to those in community hospitals
with and without teaching programs when controlling
for severity of illness. (Am J Public Health 1983;
73:25-31.)

see a different distribution of severity of illness in its patient


population from that seen in a smaller private hospital
located in a wealthy suburban area. Within a given diagnostic category, these two hospitals may have very different
profiles of patient charges or length of stay; these may be
inadequately summarized by simply reporting an average for
the whole category.
Thus, it is important to be able to characterize accurately the differences in patient severity of illness and use of
resources. We have found that a new severity of illness
index produces case mix groups which are more homogeneous with respect to resource consumption2 than case mix
groups formed by such commonly used methods as DRGs,'
New Jersey (NJ) DRGs,3 staging,4 and generalized patient
management paths.5
In this study, we have applied the new severity of illness
index to patient populations in four different types of hospitals and have compared total charges and length of stay
(LOS) across these institutions. We find that when we
control for severity of illness, the academic teaching hospital
does not have significantly higher charges than the other
hospitals in our study.

Methods

Address reprint requests to Dr. Susan D. Horn, Associate


Director, Center for Hospital Finance and Management, Division of
Health Care Organization, Department of Health Services Administration, Johns Hopkins University, 624 N. Broadway, 3rd floor,
Hampton House, Baltimore, MD 21205. This paper, submitted to
the Journal May 20, 1982, was revised and accepted for publication
August 5, 1982.
Editor's Note: See also related editorial p 14 this issue.

The severity of illness index used in our study has been


defined elsewhere.6 It is a generic (i.e., not disease-specific)
four-level index which can be added to other case mix
grouping methods. The overall four-level severity score for
an individual patient's hospital stay is determined from the

1982 American Journal of Public Health

reflect burden of illness (Table 1). The first four variables

AJPH January 1983, Vol. 73, No. 1

scores for each of seven variables which were chosen to

25

HORN
TABLE 1-Patient Severity Index
Levels

Characteristic

Moderate
Asymptomatic Manifestations

Stage of
Principal
Diagnosis

Major Manifestation

Catastrophic

None

Low

Moderate

Major

Rate

Prompt

Moderate Delay

Serious Delay

No Response

Residual

None

Minor

Moderate

Major

Complications

None or
very minor

Moderate
(less important
than principal
diagnosis)

(as or more important


than principal
diagnosis)

Catastrophic

Dependency

Low

Moderate

Major

Extreme

Procedures
(Non O.R.)

Noninvasive
Diagnostic

Therapeutic
or Invasive

Nonemergency
Life Sustaining

Life Sustaining

Interactions
Response
to
Therapy

Major

Emergency

Diagnostic
Severity rating
(circle one):

reflect primarily the patient and the burden of illness which


he or she presents to the hospital. The fifth variable,
complications, may relate both to the patient and to the
methods chosen for treatment. Variables six (patient dependency) and seven (nonoperating room procedures) may also
be influenced by the hospital procedures and staff,7 but they
have been included because they often reflect the burden of
patient illness.
To determine the severity of illness score for a patient's
stay, a rater scores each of the seven variables into one of
four levels of increasing severity by retrospectively examining data in the patient's medical record for that stay.8 The
rater then selects a severity level for the admission from a
four:point scale by implicitly integrating the values of these
seven variables. No explicit formula is given to the raters by
which to combine the values of the seven variables, since we
feel that the weights of the seven variables might vary
depending on the episode.
Procedure-adjusted severity of illness groups are created by dividing each of the above-defined severity levels into
two subgroups: those with and those without a major operating room procedure. This produces eight procedure-adjusted
severity groups.
We studied the severity of illness index in four hospitals: an academic teaching hospital (A), two community
hospitals with teaching programs (B, C), and a community
hospital with no teaching programs (D). Three of the hospitals are located on the east coast of the United States, and
one is on the west coast.
We selected six disease conditions for study in all the
hospitals-four of which are often treated medically and two
of which are often treated surgically. These diseases were
26

selected from those found to be the most heterogeneous with


respect to charges and LOS in the data sets of the Health
Care Financing Administration, the New Jersey hospitals,
and the Maryland hospitals. The six disease conditions (with
ICD9-CM codes) are: acute myocardial infarction (AMI,

410.0-410.9), congestive heart failure (CHF, 428.0-428.9),


cerebrovascular disease (CVD, 430-437.9), chronic obstructive pulmonary disease (COPD;, 491.0-496), gall bladder
disease (GBD, 574.0-576.9), and prostate disease (PROS,
600).
For each study condition in each hospital, we selected a
random sample of 100 admissions from the discharge abstract tape of admissions in the period July 1, 1979 to June
30, 1980. If the hospital did not have 100 admissions for a
particular study condition in this period, all the cases were
selected. In each of the four study hospitals, the total sample
size, combining all six disease conditions, was, respectively,
519, 600, 600, and 524. Some charts could not be located, but
every chart located was rated; the respective completion
rates were 90 per cent, 91 per cent, 88 per cent, and 91 per
cent. Each admission was rated for severity by at least five
raters and the severity rating attached to each admission was
the modal (most frequent) rating of the five or more raters.
The reliability of these different raters was high and is
described elsewhere 8

For each disease, we compared charges, costs, and


LOS within each severity level in our four hospitals. We
used both the conventional overall average obtained by
averaging charges (or costs or LOS) for all of a hospital's
patients in a disease condition, and the expected average
trimmed charge for a disease condition. The latter statistic
removes (trims) patients in those procedure-adjusted severAJPH January 1983, Vol. 73, No. 1

COMPARISONS ACROSS INSTITUTIONS

ity levels which are not treated in all hospitals and also
applies a common distribution of procedure-adjusted severity for each disease condition in each hospital. In this way,
we obtain one statistic (expected average trimmed charge or
LOS) for a disease condition in a hospital which adjusts for
differences in severity distributions and permits meaningful
comparisons across hospitals. For each disease condition, a
hospital's expected average trimmed charge (or cost or LOS)
is computed as follows: For each of the four severity levels,
take the product of a particular hospital's average charge (or
cost or LOS) and the total number of such patients in all
hospitals; sum these products over the four severity levels;
then divide by the total number of patients in all hospitals in
all the severity levels in which each hospital has at least one
patient. *
If all the patients in a disease condition from all the
study hospitals are grouped together, and if those patients
from the severity index levels not represented in all hospitals
are deleted from the group, one obtains a (trimmed) reference population of patients which can be used to compare
outputs among the hospitals. The fraction of patients in each
of the four severity levels in the reference population can be
used as weights to compute a weighted average charge for a
hospital, using its own average charges for each of the four
severity levels. This weighted average is exactly the expected average trimmed charge for the disease condition for the
hospital. Each hospital's own charge structure is used with
the same reference population to give the average charge
which would be expected if they had all treated the same
severity distribution of patients.
If a hospital's charges are monotonically increasing with
increasing severity level (as is usually the case), and if its
own patient population is more severely ill than the reference population, then its overall average charges will be
higher than its expected average trimmed charges. If its own
patient population is less severely ill than the reference
population, then its overall average charges will be less than
its expected average trimmed charges.

Results
Distribution of Severity of Illness
In Table 2 we present the severity distributions for each
of our four study hospitals and for each of the six disease
conditions. For acute myocardial infarction (AMI) and cerebrovascular disease (CVD), there is no statistically significant difference in distributions of severity of illness among
the four hospitals. For the four remaining disease conditions,
we found statistically significant differences in severity distributions. For CHF, the community teaching hospital (B)
had significantly fewer severely ill patients than the other
three hospitals. For COPD, the community non-teaching
hospital (D) had a more severe distribution than the community teaching hospital (B). For GBD and PROS, the academ*For example, in Table 3, the expected average trimmed charge
for AMI patients in the academic teaching hospital is ($2028 x 13 +
$4784 x 202 + $9538 x 43)/258 = $5437.
AJPH January 1983, Vol. 73, No. 1

ic teaching hospital (A) had a significantly more severe


distribution.
At the beginning of our study, we hypothesized that the
academic teaching hospital (A) would see a more severely ill
distribution of patients than the two community hospitals
with teaching programs (B, C), and that the least severe
distribution would be in the community hospital with no
teaching programs (D). The data in Table 2 show that the
first part of the hypothesis was confirmed for the two
surgical conditions which we studied GBD and PROS.
However, for CHF and COPD, hospital D had a more severe
distribution than hospitals B and C.
The severity index measures the burden of illness of the
patient during the whole hospitalization. Patients may be
placed in higher severity levels if they enter the hospital
more severely ill or if they become more severely ill while in
the hospital. Patients may become more severely ill through
the natural course of their illness (despite the best possible
care) or they can become more severely ill because of a lack
of sufficiently vigorous treatment. We do not know what
effect quality of care may have had on our data. This is an
area which deserves further research.

Comparison of Total Charges


In Table 3, we show the comparison of total charges in
our four study hospitals for each of the six disease conditions, controlled for severity of illness and adjusted for
procedure. We have tried to make the data more comparable
by removing deaths, miscodes, and transferred out cases
from these analyses. For all six disease conditions we found
that as severity increases so does the average charge, except
in the four medical conditions for level 4 severity patients
without procedure. This may reflect the fact that many such
patients are perceived and treated as hopeless, and are
discharged to home or a nursing home to die. For example,
two of the three patients in the academic teaching hospital
with CVD in severity level 4 without procedure had a one
day length of stay.
Note, in Table 3, that for AMI patients within each
severity level where there were enough cases, there were no
significant differences (p > .05, one way analysis of variance
F test9) in average charges in our four study hospitals.
Although for patients in severity level 3 with no procedures
the average charge in the academic teaching hospital was
$9,538 (higher than the averages in the other hospitals), the
average was not significantly higher because this high average was caused by only two of the 14 cases. When these two
outlier cases are removed, the average charge decreased to
$8,072. The low value of the F test reflects the effect of these
two outliers and yields a non-significant difference in charges
for level 3 AMI patients with no procedures among the four
hospitals.
On the other hand, we found that the CVD patients in
severity level 2, both with and without a major operating
room procedure, had significantly different average charges
(p < .025, one-way analysis of variance F test) across our
four study hospitals. For level 2 patients without procedure,
the significance is due to lower average charges in hospitals
C and D, while for level 2 patients with a major operating
27

HORN

TABLE 2-Severity Distribution by Hospital for Each Disease Condition


Hospital

A
Academic

B
Community

Disease

Teaching

Teaching

C
Community
Teaching

n=
1
2
3
4
CVD n=
1
2
3
4
CHF n=
1
2
3
4
COPD n=
1
2
3
4
GBD n=
1
2
3
4
PROS n=
1
2
3

93
4%
59
22
15
91
19%
53
14
14
88
6%
64
22
8
85
47%
46
6
1
63
49%
49
2
0
45
40%
58
2
0

96
2%
71
8
19
91
21%
46
22

84
9%
64
15
12
91
25%
46
18

11

11

86
17%
67
8
6
85
54%
37

80

AMI

7
2

95
72%
26
1
1
93
75%
21
4
0

room procedure, the significance is due to lower average


charges in the community hospital (C).
For both AMI and CVD patients, we find that the
overall average charges are highest in the academic teaching
hospital. The magnitudes of the differences in overall average charges are up to $1,723 ($6,358-$4,635) for AMI
patients and up to $3,891 ($7,441-$3,550) for CVD patients.
These overall averages do not take into account the differences in distribution of the severity of illness of the patients,
however. When the expected average trimmed charges are
computed for the academic teaching hospital they are almost
$1,000 and $2,500 less than the overall average charges for
AMI and CVD, respectively. Nevertheless, the differences
between overall average and expected average trimmed
charges are much less for the other hospitals. Thus, adjusting for the severity of illness distribution can make a great
difference for an academic teaching hospital. The magnitudes of the differences across hospitals in expected average
trimmed charges are less than $727 for AMI patients and less
than $1,368 for CVD patients.
The persistent higher charges for AMI and CVD patients in the academic teaching hospital may be due to the
following factors:
* A greater variability in resource consumption in extremely ill patients (severity levels 3 and 4);
28

5%
74
20
1
84
39%
48
13
0
93
71%
28
1
0
96
71%

29
0
0

Community
Nonteaching

Statistical

Significance

97
7%
57
16
20
96
24%
51
20
5
98
4%
61
24
11
96
38%
51
4
7
99
73%
24
3
0
24
75%
25
0
0

x2= 13.37
(p=.15)

x2= 7.25
(p > .5)

x2=

26.45

(p=.002)

x2= 20.95
(p=.02)

x2= 17.37
(p=.05)

x2= 25.57
(p=.003)

* The capability for additional treatment modalities,


i.e., an academic teaching hospital can have available more
of the sophisticated (and more costly) modalities of treatment (such as hemodynamic monitoring, lubacerebral pressure monitoring, ventillator therapy with specially trained
personnel, etc.) to apply when indicated;
* The decision to perform a major procedure (which
reflects an overall decision to make an all-out commitment to
the patient). This will greatly affect severity levels 3 and 4
charges.
The costs of treating a patient with cerebrovascular disease
are most sensitive to the philosophy of treatment. This may
be reflected in the data in Table 3.
For CHF patients, the only significant difference (p =
.01) in average charges was in severity level 3 without
procedures. This significant difference was due to the higher
charges in community teaching hospital B. For COPD the
only significant difference (p = .001) was in severity level 2
without procedures. This significant difference was due to
the low charges in the academic teaching hospital.
For CHF patients, the overall average charges are
almost the same in the four hospitals. However, when
severity is adjusted for in the expected average trimmed
charges, hospital B's charges increase while the charges for
the other three hospitals decrease. For COPD patients, the
AJPH January 1983, Vol. 73, No. 1

COMPARISONS ACROSS INSTITUTIONS

overall average is lowest in the academic teaching hospital


and remains about the same when adjusted for severity
distribution.
We find no significant differences in average charges
within severity levels for GBD patients. For PROS patients,
on the other hand, we find significant differences (p c .02)
for level 1 and level 2 patients with a major procedure. For
level 1 patients, these differences are due to generally higher
charges in the academic teaching hospital and are not due to
a few cases with high charges. For level 2 patients, the
significance is due to higher charges in the community
hospital without teaching programs. It may appear, for
PROS level 1 severity without procedure, that the academic
teaching hospital has higher average charges ($2,323), but
this is due to one high charge case. When this case is
removed, the average charges decrease to $1,371 which is in

line with or lower than charges in the other hospitals. The


lack of significance of the difference in charges for level 1
severity without procedure (F = .08, p > .5) reflects this one
outlier.
Before controlling for severity of illness, the overall
averages show that the academic teaching hospital has the
highest average charges for both gall bladder and prostate
patients. However, when we standardize the severity distribution with the expected average trimmed charge, the academic teaching hospital becomes more comparable to the
other hospitals.
All the results in this section look at total charges.
However, it is well known that charges may not adequately
reflect the cost of care. In an effort to make our comparisons
more reflective of costs, we were able to obtain the cost-tocharge ratios as well as the interest and depreciation allow-

TABLE 3-Average Total Charge (sample size In parentheses)


F-Test
Acute

Myocardial

Infarction

Severity
without
Procedure

Severity
with
Procedure

1
2
3
4
1
2
3
4

*2028 ( 1)
4784 (50)
9538 (14)
*5135( 1)

*1361 ( 1)
4835 (59)
8580( 7)
*2942 (2)

2445 ( 6)
4247 (50)
7570 (11)

3124 ( 5)
4824 (43)
8224 (11)

*2992 (1)
*6512 (1)
-

*8338 ( 2)

*14468 ( 3)
*21784( 1)

Combined

(p value)

2590 ( 13)
4675 (202)
8542 ( 43)

2.43 ( .15
.62( .60

Overall
Mean
Expected
Trimmed Mean

6358

5110

4635

5413

5437

5284

4710

5305

2024 (12)
4961 (27)
7862 (14)

1799 (20)
3526 (35)
6268 (11)

1458 (17)
2603 (45)
7589 (17)

1668 ( 59)
3741 (139)
7516 ( 46)

2.31 ( .18
7.98 ( .001)
.43 (>.5

2451 ( 4)
6260 ( 7)
13096 ( 4)
-

*3076 ( 3)
3982 ( 5)
*10846 ( 2)

*4128 ( 3)
*6138 ( 3)
_

3424( 15)
6362 ( 24)

.98 (>.5
4.13 ( .025)
3.01 ( .20

Cerebrovascular Disease

Severity
without
Procedure

Severity
with
Procedure

1
2
3
4
1
2
3
4

Overall
Mean
Expected
Trimmed Mean

1337 (10)
4550 (32)
9430 ( 4)
*3095 (3)
3990( 5)
7838 ( 9)
27733 ( 6)

*57982(1)
7441

5505

3673

3550

4923

4797

3626

3555

Congestive Heart Failure

Severity
without
Procedure

Severity
with
Procedure

Overall
Mean
Expected
Trimmed Mean

1
2
3
4

800 ( 6)
2688 (53)
4431 (16)
*16560 1)

1382 (15)
3378 (54)
12544( 5)

1
2
3
4

*20391 ( 3)

*9675 ( 2)
*10174( 2)

( 4)
(56)
(11)
(4)

1260 ( 3)
2694 (53)
5980 (19)

1229 ( 28)
3007 (216)
6323( 51)

2.26 ( .20
2.63 ( .10
4.95( .01

*5314 ( 2)
6220( 4)
_

*6246 ( 3)
*7960( 2)

11120( 11)

3.39( .18

1276
3248
6839
2068

3745

3917

3844

3686

3442

4967

3773

3300

AJPH January 1983, Vol. 73, No. 1

29

HORN

Table 3.-Continued
Chronic Obstructive Pulmonary
Disease

Severity
without
Procedure

Severity
with
Procedure

2
3
4
1
2
3
4

Overall
Mean
Expected
Trimmed Mean

F-Test

1149 (37)
1954 (38)
7585 ( 5)

999 (45)
3449 (30)
5139 ( 4)

*1781 ( 1)
*3322 (1)
*26133 (1)

1169 (33)
2939 (35)
6762 ( 9)
-

Combined

(p value)

1358 (32)
3131 (44)
7884 ( 4)

1153 (147)
2846 (147)
6858 ( 22)
*2472( 1)
*1781 ( 1)
5248 ( 4)
*26133 ( 1)

2.83 ( .08
6.49 ( .001)
.49 ( .50

*2472 (1)

*5889 ( 3)

1934

2442

2749

2657

1972

2427

2382

2637

1582 ( 7)
3050 ( 6)

2104 (16)
4048 ( 4)

1283 ( 8)
2313 ( 8)

1309 (10)
*3178 ( 1)

1661 ( 41)
2944 ( 18)

2.46 ( .16
1.53 ( .5

3229 (23)
6027 (22)
*11495 ( 1)

2723 (52)
7292 (21)
*11376( 1)
*15599 (1)

2688 (57)
5668 (18)
*27125 ( 1)

2805 (51)
5789 (22)

2798 (183)
6206 ( 83)

2.11 ( .20)
1.61 ( .4

Gall Baldder Disease

Severity
without
Procedure
Severity
with
Procedure

1
2
3
4
1
2
3
4

Overall
Mean
Expected
Trimmed Mean

4199

3911

3382

3413

3766

3876

3306

3412

2323 ( 5)
4452 (12)

*1352 ( 1)
*828 ( 1)

1910 (18)
5001 ( 7)

1969 ( 4)
*2364 ( 3)

1996 ( 27)
4342 ( 22)

.08 (>.5
2.58 ( .18

2738 (13)
5061 (13)
*9119( 1)

2282 (69)
3939 (18)
4594( 4)

2024 (50)
4434 (21)
-

2308 (14)
*7162 ( 3)
-

2231 (147)
4502 ( 56)
5499( 5)

4.47 ( .01
4.39 ( .02

Prostate

Severity
without
Procedure

Severity
with
Procedure

1
2
3
4
1
2
3
4

Overall
Mean

3990

2677

2747

2865

Expected
Trimmed Mean

3359

2424

2807

3355

*Sample size too small to be meaningful.

ances for three of our four hospitals. Reducing the total


charge results back to costs with depreciation and interest
removed did not affect the findings described above.

Comparisons of Length of Stay


We also compared hospitals with respect to LOS,
controlling for severity of illness level. We found that as
severity increases so does LOS except for level 4 patients
without procedure. The same reasoning applies here as it did
to charges. These patients are often so sick they are perceived as hopeless and are discharged to home or to a
nursing home to die. Furthermore, when there were significant differences in LOS within a severity level, they were
usually caused by lower LOS at either the academic teaching
hospital or the community non-teaching hospital or both.
30

The community non-teaching hospital is on the west coast


and it is well documented that LOS is lower in the west than
in the northeast.10 We found that this remained true even
when we controlled for severity of illness.
For the diseases AMI, CVD, and PROS, we found that
the expected average trimmed LOS in the academic teaching
hospital was about two days lower than the overall average
LOS. This is consistent with what one would expect to see if
the academic teaching hospital had a distribution of patients
more severely ill than the reference population. For the
other hospitals, the expected average trimmed LOS either
remained the same or increased from the overall average
LOS.
For the diseases CHF, COPD, and GBD, the expected
average trimmed LOS was about the same as the overall
average LOS for all the hospitals.
AJPH January 1983, Vol. 73, No. 1

COMPARISONS ACROSS INSTITUTIONS

Discussion
We have described a new severity of illness index which
is generic and has been used to classify medical and surgical
inpatients. We have found that, when we control for severity
of illness and adjust for major operating room procedure, the
differences in total charges, total costs, and LOS across
various types of hospitals frequently disappear.
Both federal and state governments are now beginning
to use discharge abstract data to form case mix groups to
compare resource consumption across hospitals. Major
teaching hospitals are often found to have the highest
resource consumption using these techniques and the opinion has been expressed that the health care industry cannot
afford the luxury of the expensive care offered in teaching
hospitals. Our results show that when resource consumption
is adjusted for severity of illness, the wide differences among
major teaching hospitals and other community hospitals in
our study disappear or become much smaller.
If severity of illness is not taken into account when
developing prospective reimbursement policies, detrimental
effects may occur which could impact the whole medical
care system in the United States. For example, it has been
proposed that medical insurance be adjusted to cover only
the average charge for a principal diagnosis or DRG in the
least expensive hospital in a community. Under such a
policy, as our data in Table 3 illustrate, a patient who went to
the academic teaching hospital for an acute myocardial
infarction would be reimbursed $4,635 (lowest overall average charge for AMI) but would have to pay out-of-pocket the
difference, $1,723 ($6,358-$4,635), or the academic teaching
hospital would have to write off the difference or not take the
patient. However, when the distribution of severity of illness
is adjusted for by using the expected average trimmed
charge, the difference is only $727 ($5,437-$4,710), almost
$1,000 less.
With increasing scrutiny of hospital costs, it is important to be able to analyze the output of a hospital so that an
institution which provides care to severely ill patients can be
differentiated from an institution which provides care to less
severely ill patients; intrinsically higher costs for the former
institution may not be unreasonable. Attempts have been
made in the past to differentiate institutions using case mix
methods which many hospital administrators and physicians

have felt were insufficiently sensitive to real differences in


burden of illness. The severity of illness index is an attempt
to correct this problem; it is now being used successfully by
several hospitals in the United States.
If a prospective reimbursement system is not instituted
in a way which adjusts for the severity of case mix, then we
may see the academic teaching hospitals selectively refusing
to take federally insured patients who do not have another
form of health insurance. As a result, we could see an
amplification of the two-tiered system of health care delivery
in this country.

REFERENCES
1. Fetter RB, Shin Y, Freeman JL, et al: Case mix definitions by
diagnosis-related groups. Med Care 1980; 18:1-53.
2. Horn SD, Sharkey PD, Bertram DA: Measuring severity of
illness: homogeneous case mix groups. Med Care (in press).
3. A Prospective Reimbursement System Based on Patient CaseMix for New Jersey Hospitals. 1976-1983. Trenton: New Jersey
State Dept of Health, September 30, 1980.
4. Garg, ML, Louis DZ, Gliebe WA, et al: Evaluating inpatient
costs: the staging mechanism. Med Care 1978; 16:191-201.
5. Young WW: Measuring the cost of care using generalized
patient management paths. Year I Final Report. Pittsburgh:
Blue Cross of Western Pennsylvania, November 1979.
6. Horn SD: The role of severity-adjusted case mix in hospital
management. Hospitals (in press).
7. Draper E, Wagner D, Knaus W: The use of intensive care: a
comparison of a university and community hospital. Health
Care Financing Review 1981; 3:49-64.
8. Horn SD, Chan C, Chachich B, Clopton C: Measuring severity
of illness: a reliability study. Med Care (in press).
9. Zar JH: Biostatistical Analysis. Englewood Cliffs, NJ: PrenticeHall Inc., 1974.
10. Bertram DA, Schumacher DN, Horn SD, Clopton CJ, Lord JG,
Chan C: Hospital case mix groupings and generic algorithms.
QRB 1982; 8:24-30.

ACKNOWLEDGMENTS
It is a pleasure to acknowledge Gregory B. Bulkley, MD for his
valuable comments, Phoebe D. Sharkey for computer analyses,
Kathleen O'Boyle as research assistant, and Susan Stern for technical administration of this study. We also acknowledge the help of
Richard Gross, MD, ScD, Gregory B. Bulkley, MD, George Roveti,
MD, FACP, Sharon Kreitzer, RN, Dale N. Schumacher, MD, MEd,
and Dennis Bertram, MD, MPH, ScD, in conceptualizing the
severity of illness index. This work was funded in part by the Health
Care Financing Administration, Grant 18P-97045.

ADDENDUM
The current version of the Severity of Illness Index is now being used by many institutions across
the United States. These institutions are collecting Severity of Illness data for purposes such as internal
hospital management, examination of differences in physician practice patterns, strategic planning, and
cross hospital comparisons. In California and Maryland there are plans to use the Severity of Illness
Index for prospective reimbursement purposes. Instead of using a case mix grouping system such as
DRGs, 19 diagnostic codes, or the CPHA-PAS A list to define the group into which a patient is placed
to set a reimbursement level, the Severity of Illness Index is used within groups of diagnostic codes
related to an organ system or to a service such as obstetrics, gynecology, or pediatrics; reimbursement
will be based on the severity level within that group.
AJPH January 1983, Vol. 73, No. 1

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