Discrepancies Between DRG-Based, Physician-Planned, and Actual Discharge Dates

A Retrospective Analysis of Oncological and Palliative Hospitalizations

The structured discharge of patients is a central objective of modern discharge management and, considering diagnosis-related groups (DRGs), an essential component of modern hospital care provision. Prolonged inpatient stays and delays can lead to medical complications, impaired quality of life, and uncoordinated transitions into follow-up care (1). Especially in oncology and palliative medicine, the demands placed on structured discharge management are great because complex disease courses and limited palliative care structures collide (2).

This retrospective analysis aims to study the discrepancy between DRG-based, physician-planned, and actual discharge dates and to identify reasons for prolonged inpatient stays of primarily oncological and palliative patients at a maximum care hospital, since this group of patients often have longer stays in hospital because of the complexity of their disease than the DRG-based system provides for.

The discharge dates to be considered are defined as follows: the DRG-based discharge date follows from the mean inpatient stay according to DRG billing data while considering the individual DRG coded diagnoses of a patient case.

The physician-planned discharge date is the date the treating doctors realistically predicted for discharge. This was set at the start of the inpatient stay or, at the latest, after exceeding the DRG-based discharge date.

The actual discharge date/date of death is the day on which patients were actually discharged or died.

Methods

In the context of the retrospective study we analyzed treatment data from 142 patients in an oncology ward and 103 patients in a palliative care ward in the time period from August 2023 and February 2024 as regards the reasons for a prolonged inpatient stay, healthcare provision before and after the inpatient stay, inclusion of social care services, and the characteristics of patient groups (Table). The particular time period was selected according to statistical advice by planned case number and patient numbers. Because of missing data sets, two palliative and six oncological patients were not included. The palliative patients received specialized inpatient complex palliative care.

Table

Characteristics and inpatient stay parameters of the oncology and palliative care patient population

The qualitative analysis of discharge delays between the actual, the physician-planned, and the DRG-based discharge date was done on the basis of doctors’ free-text entries. The determined reasons were allocated to three main categories: medical reasons, such as required treatments or newly arising complications, delays in nursing care or social-medical care services—for example, because of lacking follow-up care capacity—as well as cases without unequivocally ascertainable data.

Results

The physician-planned discharge date was closer to the actual discharge date in oncological patients than in palliative patients. In both groups, the difference between the DRG-based and actual discharge date was larger than the difference to the physician-planned discharge date. Altogether the inpatient stay in both groups was notably longer than scheduled in the DRG system.

In the analysis of the reasons, medical reasons dominated with most of the oncological and palliative groups, especially ongoing therapeutic processes or symptom control. Reasons involving nursing care services or social services were behind a prolonged inpatient stay in 13% of oncological patients and 21% of palliative patients, primarily because of lacking capacity in nursing care institutions and outpatient services.

Before their inpatient stay, 88% of the cancer patients independently looked after themselves in their homes. After the inpatient stay this rate fell to 60%. Palliative patients were in more cases looked after by nursing care services before their inpatient stay (25% versus 10%) and after their inpatient stay they received care in more cases in old people’s homes or hospices (18% versus 6%). 45% of palliative patients died during their inpatient stay.

Social services were involved in 68% of oncology cases and 93% of palliative patients with prolonged inpatient stays.

Discussion

The results of this study show exemplarily how clinical realities—especially in care provision of severely ill patients—can deviate from the rules of the DRG system and confirm this especially in the palliative setting (3). The discrepancy between medical need and economic demands constitutes a stress factor for the treating healthcare professionals and may impair the quality of the care provided.

The limitations of this evaluation include the retrospective analysis and the lacking standardized recording of the medical information, which based on individual free-text entries. As expected, the number of deaths was unevenly distributed between the groups without affecting the results. Even once deceased patients had been excluded, the discrepancy between actual/physician-planned, and DRG-based discharge dates remained the same to almost the same extent.

The results of the evaluation pertain specifically to oncology and palliative medicine and are currently not generalizable to other specialties, but the analysis highlights underlying structural problems in cross-sectoral care provision, which are likely to be much wider-ranging than affecting merely the hospital under study.

Improved discharge management—especially for oncological and palliative patients—requires in addition to staffing resources better digital interfaces, forward-planning tools, capacity building in outpatient/inpatient palliative institutions and hospices, as well as compulsory care networks, especially in patients with lacking domestic care. The results also recommend a greater consideration of nursing and social aspects when reflecting inpatient stays in the DRG system—for example, by separating out care expenditure from the DRG system or including short-term care according to § 39e Social Code V. By including this additional remuneration, the real care need would be reflected more accurately.

This, as well as the physician’s estimate as regards the discharge date may contribute to a more realistic inpatient remuneration system, improved patient care, and optimized planning of structured discharges.

Ora-Elena Kox*, Lorenz Oelschläger*, Kati Luisa Dageförde, Nikolas von Bubnoff, Cyrus Khandanpour

Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Klinik für Hämatologie, Onkologie und Palliativmedizin,[e-mail]

*Die Autorin und der Autor teilen sich die Erstautorenschaft

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 31 July 2025, revised version accepted on 20 November 2025.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as
Kox OE, Oelschläger L, Dageförde KL, von Bubnoff N, Khandanpour C: Discrepancies between DRG-based, physician-planned, and actual discharge dates: A retrospective analysis of oncological and palliative hospitalizations. Dtsch Arztebl Int 2026; 123: 82–3. DOI: 10.3238/arztebl.m2025.0224

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3. Gudat H: Der Wert des Lebensendes: Am Beispiel der Finanzierung der stationären spezialisierten Palliative Care in der Schweiz. Ther Umsch 2018; 75: 127–34