Impact of DRGs-based inpatient service management on the performance of regional inpatient services in Shanghai, China: an interrupted time series study, 2013-2019

Can single disease payment impact hospitalization expenses and quality in district hospital? A case study in Fujian, China

BACKGROUND

China is exploring payment reform methods for patients to address the escalating issue of increasing medical costs. While most district hospitals were still in the stage of Single Disease Payment (SDP) due to conditions, there is a scarcity of research on comprehensive assessment of SDP. This study aims to evaluate the implementation of SDP in a district hospital, and provided data support and scientific reference for improving SDP method and accelerating medical insurance payment reform at district hospitals.

METHODS

Data was collected from 2337 inpatient medical records at a district hospital in Fuzhou, China from 2016 to 2021. These diagnoses principally included type 2 diabetes, planned cesarean sections, and lacunar infarction. Structural variation analysis was conducted to examine changes in the internal cost structure and dynamic shifts in medical expenses for both the insured (treatment group) and uninsured (control group) patients, pre- and post-implementation of the SDP policy on August 1, 2018. The difference-in-differences (DID) method was employed to assess changes in hospitalization expenses and quality indicators pre- and post-implementation. Furthermore, subjective evaluation of medical quality was enhanced through questionnaire surveys with 181 patients and 138 medical staff members.

RESULTS

The implementation of SDP decreased the medical expenses decreased significantly (P < 0.05), which can also optimize the cost structure. The drug cost ratio descended significantly, and the proportion of laboratory fee rose slightly. The changes in infection rate, cure rate, and length of stay indicated enhanced medical quality (P < 0.05). The satisfaction of inpatients with SDP was high (89.2%). Medical staff expressed an upper middle level of satisfaction (77.2%) but identified difficulties with the implementation such as "insufficient coverage of disease types".

CONCLUSION

After the implementation of SDP in district hospitals, considerable progress has been achieved in restraining medical expenses, coupled with notable enhancements in both medical quality and patient satisfaction levels. However, challenges persist regarding cost structure optimization and underutilization of medical resources. This study suggests that district hospitals can expedite insurance payment reform by optimizing drug procurement policies, sharing examination information, and strengthening the management of medical records.

Differences in inpatient performance of public general hospitals following implementation of a points-counting payment based on diagnosis-related group: a robust multiple interrupted time series study in Wenzhou, China

OBJECTIVES

This study measures the differences in inpatient performance after a points-counting payment policy based on diagnosis-related group (DRG) was implemented. The point value is dynamic; its change depends on the annual DRGs' cost settlements and points of the current year, which are calculated at the beginning of the following year.

DESIGN

A longitudinal study using a robust multiple interrupted time series model to evaluate service performance following policy implementation.

SETTING

Twenty-two public general hospitals (8 tertiary institutions and 14 secondary institutions) in Wenzhou, China.

INTERVENTION

The intervention was implemented in January 2020.

OUTCOME MEASURES

The indicators were case mix index (CMI), cost per hospitalisation (CPH), average length of stay (ALOS), cost efficiency index (CEI) and time efficiency index (TEI). The study employed the means of these indicators.

RESULTS

The impact of COVID-19, which reached Zhejiang Province at the end of January 2020, was temporary given rapid containment following strict control measures. After the intervention, except for the ALOS mean, the change-points for the other outcomes (p<0.05) in tertiary and secondary institutions were inconsistent. The CMI mean turned to uptrend in tertiary (p<0.01) and secondary (p<0.0001) institutions compared with before. Although the slope of the CPH mean did not change (p>0.05), the uptrend of the CEI mean in tertiary institutions alleviated (p<0.05) and further increased (p<0.05) in secondary institutions. The slopes of the ALOS and TEI mean in secondary institutions changed (p<0.05), but not in tertiary institutions (p>0.05).

CONCLUSIONS

This study showed a positive effect of the DRG policy in Wenzhou, even during COVID-19. The policy can motivate public general hospitals to improve their comprehensive capacity and mitigate discrepancies in treatment expenses efficiency for similar diseases. Policymakers are interested in whether the reform successfully motivates hospitals to strengthen their internal impetus and improve their performance, and this is supported by this study.

Evaluation of inpatient services of tertiary comprehensive hospitals based on DRG payment

Objective

This study aims to evaluate inpatient services in 49 tertiary comprehensive hospitals using indicators from the diagnosis related groups (DRG) payment system.

Method

DRG data from 49 tertiary comprehensive hospitals were obtained from the quality monitoring platform for provincial hospitals, and relevant indicators were identified. The analytic hierarchy process (AHP) was used to compute the weight of each indicator. The rank sum ratio method was used to calculate the weight rank sum ratio (WRSR) value and the corresponding probit value of each hospital. The hospitals were divided into four grades based on the threshold value: excellent, good, fair, and poor.

Results

Eight indicators of the 49 hospitals were scored, and the hospital rankings of indicators varied. The No. 1 hospital ranked first in the indicators of "total number of DRG", "number of groups", and "proportion of relative weights (RW) ≥ 2". The WRSR value of the No.1 hospital was the largest (0.574), and the WRSR value of the No. 44 hospital was the smallest (0.139). The linear regression equation was established: WRSRpredicted =-0.141+0.088*Probit, and the regression model was well-fitted (F = 2066.672, p < 0.001). The cut-off values of the three WRSRspredicted by the four levels were 0.167, 0.299, and 0.431, respectively. The 49 hospitals were divided into four groups: excellent (4), good (21), average (21), and poor (3). There were significant differences in the average WRSR values of four categories of hospitals (p < 0.05).

Conclusion

There were notable variances in the levels of inpatient services among 49 tertiary comprehensive hospitals, and hospitals of the same category also showed different service levels. The evaluation results contribute to the health administrative department and the hospital to optimize the allocation of resources, improve the DRG payment system, and enhance the quality and efficiency of inpatient services.

Comprehensive evaluation of disease coding quality in gastroenterology and its impact on the diagnosis-related group system: a cross-sectional study

OBJECTIVE

According to the diagnosis-related group (DRG) requirement, issues of diagnosis and procedure coding in the gastroenterology department of our hospital were analyzed and improvement plans were proposed to lay the foundation for effective implementation of DRGs.

METHODS

The title page of case-history of 1600 patients admitted to the Department of Gastroenterology of this hospital from January 1, 2021 to December 31, 2021 was sampled as a data source, and the primary and other diagnostic codes, operation or procedure codes involved in the title page of case-history were categorized and statistically analyzed.

RESULTS

Of the 531 cases treated with gastrointestinal endoscopy in our hospital in 2021, coding errors were identified in 66 cases and unsuccessful DRG enrollment in 35 cases, including 14 cases with incorrect coding of the primary diagnosis (8 cases with unsuccessful DRG enrollment), 37 cases with incorrect coding of the primary operation (23 cases with unsuccessful DRG enrollment), and 8 cases with incorrect coding of both the primary diagnosis and the primary operation (4 cases with unsuccessful DRG enrollment). Analysis of 66 inpatient cases with coding problems showed a total of 167 deficiencies, including 36 deficiencies in major diagnoses, 84 deficiencies in other diagnoses, and 47 deficiencies in surgery or operation coding.

CONCLUSION

The accuracy of coding of disease diagnosis and surgical operation is the basis for the smooth implementation of DRGs. The medical staff of this hospital has poor cognition of DRGs coding and fails to recognize the important role of the title page of case-history quality to DRGs system, and their attention to DRGs and knowledge base of disease classification coding should be improved. In addition, the high incidence of coding errors, especially the omission of disease diagnosis, requires increased training of physicians and nurses on clinical knowledge and requirements for DRGs medical records, thereby improving the quality of medical cases and ensuring the accuracy of DRGs information.

Measuring and improving performance of clinicians: an application of patient-based records

BACKGOUND

Efforts to measure performance and identify its driving factors among clinicians are needed for building a high-quality clinician workforce. The availability of data is the most challenging thing. This paper presented a summary performance measure for clinicians and its application on examining factors that influence performance using routine patient-based records.

METHODS

Perfomance indicators and difficulty score were extracted from electronic medical records (EMRs). Difficulty adjustment and standardized processing were used to obtain indicators which were comparable between specialties. Principal component analysis (PCA) was used to estimate the summary performance measure. The performance measure was then used to examine the influence of person-job fit and burnout through a mediator effect model and cluster analysis.

RESULTS

A valid sample of 404 clinicians were included in this study, and 244 of them had valid response in the questionnaire. PCA explained 79.37% of the total variance presented by the four adjusted performance indicators. Non-performance attributes and performance driving factors help distinguish different clusters of clinicians. Burnout mediates the relationship between person-job fit and performance in a specific group of clinicians (β = 0.120, p = 0.008).

CONCLUSIONS

We demonstrated the analytical steps to estimate clinicians' performance and its practical application using EMRs. Our findings provide insight into personnel classified management. Such practice can be applied in countries where electronic medical record systems are relatively less developed to continuously improve the application of performance management.

The impact of China's zero markup drug policy on drug costs for managing Parkinson's disease and its complications: an interrupted time series analysis

Background

In April 2009, the Chinese government launched Zero Markup Drug Policy (ZMDP) to adjust medical institutions' revenue and expenditure structures.

Objective

This study evaluated the impact of implementing ZMDP (as an intervention) on the drug costs for managing Parkinson's disease (PD) and its complications from the healthcare providers' perspective.

Methods

The drug costs for managing PD and its complications per outpatient visit or inpatient stay were estimated using electronic health data from a tertiary hospital in China from January 2016 to August 2018. An interrupted time series analysis was conducted to evaluate the immediate change following the intervention (step change, β₁) and the change in slope, comparing post-intervention with the pre-intervention period (trend change, β₂). Subgroup analyses were conducted in outpatients within the strata of age, patients with or without health insurance, and whether drugs were listed in the national Essential Medicine List (EML).

Results

Overall, 18,158 outpatient visits and 366 inpatient stays were included. Outpatient (β₁ = -201.7, 95%CI: -285.4, -117.9) and inpatient (β₁ = -372.1, 95% CI: -643.6, -100.6) drug costs for managing PD significantly decreased when implementing ZMDP. However, for outpatients without health insurance, the trend change in drug costs for managing PD (β₂ = 16.8, 95% CI: 8.0, 25.6) or PD complications (β₂ = 12.6, 95% CI: 5.5, 19.7) significantly increased. Trend changes in outpatient drug costs for managing PD differed when stratifying drugs listed in EML (β₂ = -1.4, 95% CI: -2.6, -0.2) or not (β₂ = 6.3, 95%CI: 2.0, 10.7). Trend changes of outpatient drug costs for managing PD complications significantly increased in drugs listed in EML (β₂ = 14.7, 95% CI 9.2, 20.3), patients without health insurance (β₂ = 12.6, 95% CI 5.5, 19.7), and age under 65 (β₂ = 24.3, 95% CI 17.3, 31.4).

Conclusions

Drug costs for managing PD and its complications significantly decreased when implementing ZMDP. However, the trend in drug costs increased significantly in several subgroups, which may offset the decrease at the implementation.

Application of DRGs in hospital medical record management and its impact on service quality

BACKGROUND

To explore the application of diagnosis-related groups (DRGs) in hospital medical record management and the impact on service quality.

OBJECTIVE

This study introduced DGRs management into hospital medical record management in order to improve the quality of hospital medical record management.

METHOD

The medical record management of our hospital was analysed retrospectively between August 2020 and April 2021. A total of 7263 cases without DRG management before January 2021 were included in a control group, and 7922 cases with DRG management after January 2021 were included in a study group. The error rate of medical records, the specific error items and the scores of service capability, service efficiency and service quality were compared along with the comprehensive scores of the two groups.

RESULTS

The error rate of medical records in the study group was significantly lower than that in the control group (19.35% vs. 31.24%, P < 0.05). The error rates in terms of diagnosis on admission, surgical procedures, main diagnosis and other diagnoses in the study group were significantly lower than those in the control group. The scores for service ability, service efficiency and service quality were significantly higher in the study group than in the control group (P < 0.05). The comprehensive evaluation score of the study group was significantly higher than that of the control group (P < 0.01).

CONCLUSION

Applying DRGs in the hospital medical record management can effectively reduce the error rate of medical records and improve the quality of hospital services.

A taxonomy of Chinese hospitals and application to medical dispute resolutions

Medical disputes can be viewed as a negative indicator of health care quality and patient satisfaction. However, dispute prevention from the perspective of systematic supervision is unexplored. This study examines hospital clustering based on diagnosis-related group (DRG) indicators and explores the association between hospital clusters and medical disputes. Health administrative data from Sichuan Province in 2017 were used. A twostep cluster analysis was performed to cluster hospitals based on DRG indicators. A multiple regression analysis was conducted to evaluate the relationship between clusters and the incidence/number of medical disputes. The 1660 hospitals were grouped into three DRG clusters: basic (62.5%, n = 1038), diverse (31.0%, n = 515), and lengthy (6.4%, n = 107). After adjusting for covariates, the diverse hospitals were associated with an increased probability of having medical disputes (OR 5.24, 95% CI 2.97-9.26), while the diverse and lengthy hospitals were associated with a greater number of medical disputes (IRR 10.67, 95% CI 6.58-17.32; IRR 4.06, 95% CI 1.22-13.54). Our findings highlighted that the cluster-level performance of hospitals can be monitored. Future studies could examine this relationship using a longitudinal design and explore ways to reduce medical disputes in hospitals.

The DEMATEL method explores the interdependent relationship structure and weights for diagnosis-related groups system

Purpose

This study constructs a structure of interaction between dimensions and criteria within the diagnosis-related groups (DRGs) system from a quantitative system and identifies key factors affecting the overall performance of medical services.

Method

From September to December 2020, the influence relation structure diagram (IRSD) of the dimensions and corresponding criteria was developed from the practical experience of a group of domain experts, based on the DEMATEL method. Subsequently, all dimensions and criteria construct influential weights from a systems perspective. Finally, the main influential factors were identified based on the analysis results.

Results

The IRSD results showed that, in the overall performance of medical services, “Medical service capacity (C₁)” was the main influential dimension, influencing both “Medical service efficiency (C₂)” and “Medical service safety (C₃).” At the criteria level, “Case-mix index (CMI) (C₁₂),” “Time efficiency index (C₂₁),” and “Inpatient mortality of medium-to-low group (C₃₂)” were the main influential criteria in the corresponding dimensions. The influential weight results showed that “Medical service capacity (C₁)” was also a key dimension. “Case-mix index (CMI) (C₁₂),” “Cost efficiency index (C₂₂),” and “Inpatient mortality of medium-to-low group (C₃₂)” were the key criteria in their respective dimensions.

Conclusion

Patients and managers should first focus on the capacity of medical service providers when making a choice or deciding using the results of the DRGs system. Furthermore, they should pay more attention to medical safety even if it is not as weighted as medical efficiency.