Australian diagnosis related groups: Drivers of complexity adjustment

BackgroundIn undertaking a major revision to the Australian Refined Diagnosis Related Group (ARDRG) classification, we set out to contrast Australia's approach to using data on additional (not principal) diagnoses with major international approaches in splitting base or Adjacent Diagnosis Related Groups (ADRGs).MethodsComparative policy analysis/narrative review of peer-reviewed and grey literature on international approaches to use of additional (secondary) diagnoses in the development of Australian and international DRG systems.AnalysisEuropean and US approaches to characterise complexity of inpatient care are well-documented, providing useful points of comparison with Australia's. Australia, with good data sources, has continued to refine its national DRG classification using increasingly sophisticated approaches. Hospital funders in Australia and in other systems are often under pressure from provider groups to expand classifications to reflect clinical complexity. DRG development in most healthcare systems reviewed here reflects four critical factors: these socio-political factors, the quality and depth of the coded data available to characterise the mix of cases in a healthcare system, the size of the underlying population, and the intended scope and use of the classification. Australia's relatively small national population has constrained the size of its DRG classifications, and development has been concentrated on inpatient care in public hospitals.Discussion and conclusionsDevelopment of casemix classifications in health care is driven by both technical and socio-political factors. Use of additional diagnoses to adjust for patient complexity and cost needs to respond to these in each casemix application.     

中医住院按病种付费管理的绩效评价指标体系构建——基于德尔菲法和层次分析法

目的：本研究旨在构建中医住院按病种付费管理的绩效评价指标体系,确定指标及权重,为中医按病种付费绩效评价提供参考。方法：利用文献研究法初步构建指标池,运用德尔菲法进行两轮专家咨询,确定评价指标体系,采用层次分析法确定指标权重。结果：经两轮专家咨询后,建立了中医住院按病种付费管理绩效评价指标体系,包含3个一级指标、10个二级指标、29个三级指标。专家积极程度、权威程度、意见协调程度均较好。层次分析法结果显示指标一致性程度较高。结论：初步构建了中医住院按病种付费管理绩效评价指标体系,具有较高的科学性和可靠性,可用于中医住院按病种付费管理的绩效评价,但仍需在今后的推广应用过程中不断进行动态调整。     

疾病诊断相关组和医师费评价医师绩效的比较

随着公立医院绩效制度改革的深入,主治医师绩效评价越来越重要。本研究以北京清华长庚医院2016年5月至2017年3月的住院服务的实际数据为例,采用医师费（PF）和疾病诊断相关组（DRGs）两种方案计算,计算结果表明,两方案的导向性一致,均可起到控费效果。     

Measuring case-mix complexity of tertiary care hospitals using DRGs

The objectives of the study were to develop a model that measures and evaluates case-mix complexity of tertiary care hospitals, and to examine the characteristics of such a model. Physician panels defined three classes of case complexity and assigned disease categories represented by Adjacent Diagnosis Related Groups (ADRGs) to one of three case complexity classes. Three types of scores, indicating proportions of inpatients in each case complexity class standardized by the proportions at the national level, were defined to measure the case-mix complexity of a hospital. Discharge information for about 10% of inpatient episodes at 85 hospitals with bed size larger than 400 and their input structure and research and education activity were used to evaluate the case-mix complexity model. Results show its power to predict hospitals with the expected functions of tertiary care hospitals, i.e. resource intensive care, expensive input structure, and high levels of research and education activities.     

Describing Iranian hospital activity using Australian Refined DRGs: a case study of the Iranian Social Security Organisation

OBJECTIVE: To describe Iran's hospital activity with Australian Refined Diagnosis Related Groups (AR-DRGs). METHOD: A total of 445,324 separations was grouped into discreet DRG classes using AR-DRGs. L(3)H(3); IQR and 10th-95th percentile were used to exclude outlier cases. Reduction in variance (R(2)) and coefficient of variation (CV) were applied to measure model fit and within group homogeneity. RESULTS: Total hospital acute inpatients were grouped into 579 DRG groups in which 'surgical' cases represented 63% of the total separations and 40% of total DRGs. Approximately 12.5% of the total separations fell into DRGs O60C (vaginal delivery) and 28% of the total separations classified into major diagnostic category (MDC) 14 (pregnancy and childbirth). Although reduction in variance (R(2)) for untrimmed data was low (R(2)=0.17) for LOS, trimming by L(3)H(3), IQR, and 10th-95th percentile methods improved the value of R(2) to 0.53, 0.48, and 0.51, respectively. Low value of R(2) for AR-DRGs within several MDCs were identified, and found to reflect high variability in one or two DRGs. High within-DRG variation was identified for 23% of DRGs using untrimmed data. CONCLUSION: Low quality and incomplete data undermines the accuracy of casemix information. This may require improvement in coding quality or further classification refinement in Iran. Further study is also required to compare AR-DRG performance with other versions of DRGs and to determine whether the low value of R(2) for several MDCs is due to the weakness of the AR-DRG algorithm or to Iranian specific factors.     

评估和控制分解住院的方法初探

目的 模拟判别分解住院的过程,为建立评估分解住院的可操作方法提供依据.方法 从北京市公共卫生信息中心采集2010年北京市全部出院病例的病案首页信息.以“北京版诊断相关组(BJ-DRGs)”为风险调整工具,分别在地区层面和医院层面计量各DRGs的两周再入院率.比对并筛选出分解住院的“可疑对象”.继而针对“可疑对象”进行病例数据细致检验,判断是否存在分解住院的情况.结果 2010年北京市有13类疾病的两周再入院率超过10％.以11家三甲医院“痴呆及其他慢性大脑功能失调”两周再入院率比较为例.比较后发现,G医院为可疑对象.进行病例细致分析后,发现了G医院在该类病例分解住院的情况.结论 借助DRGs作为风险调整工具,充分利用客观数据结合“标杆法“筛查可疑对象,有助于降低分解住院的监管成本.     

运用疾病诊断相关组进行临床服务绩效评价初探

目的 探索客观有效地评价医院临床服务绩效的办法.方法 利用澳大利亚诊断相关组系统（AR-DRGs）的分组原理,对北京市8家三级综合公立医院2003～2005年出院病例首页数据进行分组.以医疗费用和住院时间为基础构建绩效评价指标,对医院整体服务绩效进行评价.比较引入诊断相关组（DRGs）前后绩效评价的结果,进而阐明DRGs对医院服务绩效评价的作用.结果 无论是医院自身的纵向比较还是医院之间的横向比较,引入DRGs的绩效评价结果与不引入DRGs相比,差异明显.结论 引入DRGs有利于绩效评价指标的标准化,从而使评价结果更加可靠     

新医改伦理价值的实践困境与政策应对——以按病种付费政策为例

新医改的政策应当遵循总效原则、不伤害原则、公平正义原则等公共政策的伦理价值标准。按病种付费制度作为新医改中的重要政策在全国范围内的试点与推广,在抑制医疗费用增长过快和过度医疗方面发挥了重要作用。在伦理价值向度上,按病种付费制度规避了不道德的个体、遵循了新医改的总效原则、实现了社会保障的公正思想,但也产生了抑制个体健康需求、增加医疗机构的伦理风险以及对医学科研发展产生消极影响等方面的问题。要实现按病种付费制度的合理发展,需要完善按病种付费自身的制度建设,保障政策的合理可行;建立有序的配套措施,保障制度的推广与实施;增加政府的财政投入,保障公立医院的公益性;建立良好的沟通机制,加强医疗机构与保险机构的互动等。     

病例组合指数的内涵及应用探讨

国内普遍认为病例组合指数(CMI)属于医疗服务能力维度,体现收治疾病的疑难复杂程度和医疗服务的整体技术难度。通过结构方程模型分析发现,CMI与时间消耗指数、费用消耗指数等服务效率维度指标联系更紧密,与DRG组数、入组病例数及总权重等服务能力维度指标联系相对较弱,故应归属医疗服务效率维度。CMI的直接应用主要是对平均住院费用的预测控制及对科室绩效的评价;CMI的间接应用主要是对管理指标的调整/校正。医院管理者应准确把握CMI内涵,恰当应用CMI对不同层级及不同类别住院费用进行预测、评价与控制,并对其他管理指标进行调整后再评价。     

澳大利亚疾病诊断相关分组预付费模式运作机制及效果评价

对澳大利亚疾病诊断相关分组(DRGs)预付费模式的背景、方法、流程、实施效果和存在问题进行分析,认为该模式在一定程度上能够提高医院运行效率、控制医疗费用增长,是目前世界上较好的一种医疗费用支付模式。     

Cost accounting to determine prices: How well do prices reflect costs in the German DRG-system?

Germany has recently introduced a system of Diagnosis Related Groups (DRGs) to engender more appropriate resource allocation. The following article describes the German DRG-system and the methodologies used to determine prices. It analyses the extent to which prices, or calculated cost weights, reflect the actual costs incurred by hospitals for their respective services. We reveal that a “compression” of DRG cost weights occurs, and that the data sample used to calculate cost weights is lacking in terms of its representativeness. Although cost data accuracy has improved over the last few years there are still a number of challenges that need to be addressed.     

An evaluation of a model for the systematic documentation of hospital based health promotion activities: results from a multicentre study

Background  

The first step of handling health promotion (HP) in Diagnosis Related Groups (DRGs) is a systematic documentation and registration of the activities in the medical records. So far the possibility and tradition for systematic registration of clinical HP activities in the medical records and in patient administrative systems have been sparse. Therefore, the activities are mostly invisible in the registers of hospital services as well as in budgets and balances.     

Recommendations for the use of hospital statistics for hospital planning and management

The trend towards DRGs (Diagnosis Related Groups) represents a major step in the development of hospital information systems. Based on the experience with the use of routine hospital data in the Swiss DRG project, this article presents recommendations in five areas: 1. Data collection and coding of medical routine data in hospitals 2. Continuous monitoring of the computer algorithm used to group diagnoses ("Grouper") 3. Methodology of calculating costs 4. Use of DRGs in planning and management; and finally 5. Strategies to implement these recommendations     

运用DRGs工具对老年医院诊治能力及效率进行评价的探讨

目的 应用DRGs评价系统对老年医院诊治能力及效率进行评价,提升医院的管理水平。方法 以2018年15 096份住院病案首页数据为研究对象,使用“北京版诊断相关组(BJ-DRGs)”作为风险调整工具,从病例组合指数（CMI）、时间消耗指标、费用消耗指标、住院例均费用和医疗安全等方面进行分析,探讨DRGs工具对老年医院诊治能力及效率的评价效果。结果 老年医院MDC为22个,DRGs组数为437组, CMI、时间消耗指数和费用消耗指数分别超过老年病专业和北京市医院平均水平,低风险死亡率为0,中高组和高风险组病例数占比高于全市水平,死亡率低于全市水平。结论 通过DRGs数据分析能够发现老年医院、老年医学专业与综合医院专业科室在收治常见疾病上的差异,优化老年医院资源配置,改进医疗服务质量和水平。建议在使用DRG工具评价老年医学专业时,应考虑老年患者年龄、多病共存等因素影响,完善老年医学专业的医疗效率绩效指标个性化设定。     

Use of diagnosis related groups for hospital management.

This paper gives an overview on the use of Diagnosis Related Groups (DRGs) for internal hospital management. Some figures derived from a comparative study between 3 university hospitals in Belgium are used to illustrate specific points. Attention is given to cost accounting and cost control on the one hand, and utilization review and quality assurance testing on the other. Costs have been approximated by billed charges. It is concluded that DRGs can effectively be used for hospital management, in addition to hospital financing for which some pressure also exists in Europe.     

按DRGs组合方式制定消化系统疾病患者住院费用的研究

目的 制定消化系统疾病患者的住院费用.方法 利用DRGs病例组合方法 ,对1995～2000年云南省五所综合性医院收治的消化系统疾病住院患者进行分组,并计算出各病例组合的中位数,几何均数和上限.结果 对于67722例消化系统住院患者,我们共形成80个DRGs组合和相对应住院费用标准.结论 提出了以DRCs组合方式为基础,探索制定住院费用收费标准的方法 .     

The implementation of DRG-based hospital reimbursement in Switzerland: A population-based perspective

Background  

Switzerland introduces a DRG (Diagnosis Related Groups) based system for hospital financing in 2012 in order to increase efficiency and transparency of Swiss health care. DRG-based hospital reimbursement is not simultaneously realized in all Swiss cantons and several cantons already implemented DRG-based financing irrespective of the national agenda, a setting that provides an opportunity to compare the situation in different cantons. Effects of introducing DRGs anticipated for providers and insurers are relatively well known but it remains less clear what effects DRGs will have on served populations. The objective of the study is therefore to analyze differences of volume and major quality indicators of care between areas with or without DRG-based hospital reimbursement from a population based perspective.     

Payment policy for chemotherapy in public hospitals: a case for splitting DRG 780/R63Z

OBJECTIVE: To assess the appropriateness of the current way chemotherapy is classified in the Australian casemix classification system. METHOD: Secondary analysis of patient-level data for all cases of DRG 780 separated from Victorian hospitals with clinical costing systems in the years 1994/95, 1995/96 and 1996/97 using the Chi-squared Automatic Interaction Detector (CHAID) option of Answer Tree Version 2.0. RESULTS: Different cancers have different costs. There is a significant difference (F=316.8, df=4, 11091, p=0.00) between the cost of colon cancer (mean=$289), breast cancer (mean=$481), lymphatic cancer (mean=$605), leukemia (mean=$1,118) and other cancers (mean=$512). The differences are sufficiently large that they meet the statistical criteria for splitting a DRG. CONCLUSION: Application of nationally agreed criteria for creation of Diagnosis Related Groups suggests that the existing DRG 780 should be split into five groups: colon, breast and lymphatic cancers, leukemia and a residual 'other cancers' category. The new groups increase the explanation of variation in costs (about a 10% reduction in variance). IMPLICATIONS: It is no longer valid for casemix development to be based on length of stay as a proxy for resource utilisation, especially for DRGs that are primarily same day.     

按病种定额预付制的可行性探讨

探讨按病种的定额预先付费(DRGs-PPS)对按服务的事后付费(fee-for-service)改革的可行性。DRGs-PPS起源于美国，并在欧洲等相继推广，对提高医院效率、评价医疗服务质量、控制住院费用等方面有显著作用，可产生重大社会效益与经济效益。但实行DRGs-PPS存在管理难度大、服务打折、费用转嫁等问题。以各医院的平均病种费用试行预先支付制度，总量控制，是一种较好的可行方法。     

新医改背景下国内疾病诊断相关分组研究现状与热点文献计量学与可视化分析

目的 利用文献计量学方法分析新医改以来国内疾病诊断相关分组（Diagnosis Related Groups, DRGs）研究现状和前沿热点,以期为我国DRGs领域研究与实践提供借鉴。 方法 通过检索中国知网、维普、万方数据库,获取新医改以来国内DRGs研究文献相关信息,并运用信息可视化软件VOSviewer绘制知识图谱。 结果 共纳入文献1884篇;2016年后发文量快速增加;高产期刊较多,而文章质量仍需提升;核心作者已形成11个研究团队,团队间缺乏合作;研究热点集中在医保支付方式改革、绩效评价、成本核算、临床路径、病案首页与决策树等方面。 结论 新医改以来,国内DRGs研究内容不断深化,且注重实践操作层面研究,研究热点丰富;DRGs研究内容、重点与深度等急需进一步深化。