The Effect of Diagnosis-Related Group Payment System on Quality of Care in the Field of Obstetrics and Gynecology among Korean Tertiary Hospitals

Hospital response to Activity-Based Funding and price incentives: Evidence from Ireland

Activity-Based Funding (ABF) is a funding policy incentivising hospitals to deliver more efficient care. ABF can be complemented by additional price incentives to further drive hospital efficiency. In 2016, ABF was introduced for public patients admitted to Irish public hospitals. Additionally, a price incentive to perform laparoscopic cholecystectomy as day-case surgery was introduced in 2018. Private patient activity in public hospitals was subject to neither ABF nor price incentive. Using national Hospital In-Patient-Enquiry activity data 2013-2019, we evaluated the impact of ABF and the price incentive for laparoscopic cholecystectomy surgery in Ireland. We exploit variation in hospital payment for public and private patients treated in public acute Irish hospitals and employ a Propensity Score Matching Difference-in-Differences approach. We estimate the funding change impacts across outcomes measuring the proportion of day-case admissions and length of stay. We found no significant impact for either outcomes linked to ABF introduction. Similarly, no impacts linked to the price incentive were observed. It appears providers of laparoscopic cholecystectomy in Irish public hospitals did not react to the new funding mechanisms. The implementation of the funding policies did not improve hospital efficiency. Further strengthening of these new funding mechanisms are required to deliver more efficient care.

A study of the types and manifestations of physicians' unintended behaviors in the DRG payment system

Introduction

In recent years, China has implemented the Diagnosis Related Groups (DRG) payment system as part of its healthcare insurance reimbursement policy. Numerous studies have focused on the effectiveness of DRG payment system in controlling unreasonable growth in medical expenses. However, there has been no systematic report on the types of unintended behaviors exhibited by doctors under the DRG payment system.

Methods

The study first utilized interrupted time series analysis to analyze medical records and insurance data from eight hospitals. It investigated the data changes in MDC and ADRG groups before and after the implementation of the DRG payment system. Subsequently, a semi-structured interview method was employed to conduct qualitative research on the unintended behaviors of physicians, aiming to gain a more accurate understanding of specific changes in physician behavior after the implementation of the DRG payment system.

Results

This study discovered that doctors engage in unintended behaviors within the framework of the DRG payment system.

Discussion

In the early implementation of the DRG payment system in China, the contradictions between the flawed DRG payment methods and supporting systems and the actual diagnostic and treatment work manifested in the form of unintended doctor behaviors. Most of these unintended behaviors can be considered reasonable feedback from doctors to cope with the existing system flaws. They are conducive to identifying the deficiencies in China's DRG payment system and suggesting directions for improvement.

Does prospective payment influence quality of care? A systematic review of the literature

In the light of rising health expenditures, the cost-efficient provision of high-quality inpatient care is on the agenda of policy-makers worldwide. In the last decades, prospective payment systems (PPS) for inpatient care were used as an instrument to contain costs and increase transparency of provided services. It is well documented in the literature that prospective payment has an impact on structure and processes of inpatient care. However, less is known about its effect on key outcome indicators of quality of care. In this systematic review, we synthesize evidence from studies investigating how financial incentives induced by PPS affect indicators of outcome quality domains of care, i.e. health status and user evaluation outcomes. We conduct a review of evidence published in English, German, French, Portuguese and Spanish language produced since 1983 and synthesize results of the studies narratively by comparing direction of effects and statistical significance of different PPS interventions. We included 64 studies, where 10 are of high, 18 of moderate and 36 of low quality. The most commonly observed PPS intervention is the introduction of per-case payment with prospectively set reimbursement rates. Abstracting evidence on mortality, readmission, complications, discharge disposition and discharge destination, we find the evidence to be inconclusive. Thus, claims that PPS either cause great harm or significantly improve the quality of care are not supported by our findings. Further, the results suggest that reductions of length of stay and shifting treatment to post-acute care facilities may occur in the course of PPS implementations. Accordingly, decision-makers should avoid low capacity in this area.

Impact of Diagnosis-Related Groups on Inpatient Quality of Health Care: A Systematic Review and Meta-Analysis

The aim of this meta-analysis was to comprehensively evaluate the effectiveness of Diagnosis-related group (DRG) based payment on inpatient quality of care. A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science from their inception to December 30, 2022. Included studies reported associations between DRGs-based payment and length of stay (LOS), re-admission within 30 days and mortality. Two reviewers screened the studies independently, extracted data of interest and assessed the risk of bias of eligible studies. Stata 13.0 was used in the meta-analysis. A total of 29 studies with 36 214 219 enrolled patients were analyzed. Meta-analysis showed that DRG-based payment was effective in LOS decrease (pooled effect: SMD = -0.25, 95% CI = -0.37 to -0.12, Z = 3.81, P < .001), but showed no significant overall effect in re-admission within 30 days (RR = 0.79, 95% CI = 0.62-1.01, Z = 1.89, P = .058) and mortality (RR = 0.91, 95% CI = 0.72-1.15, Z = 0.82, P = .411). DRG-based payment demonstrated statistically significant superiority over cost-based payment in terms of LOS reduction. However, owing to limitations in the quantity and quality of the included studies, an adequately powered study is necessary to consolidate these findings.

Performance assessment of medical service for organ transplant department based on diagnosis-related groups: A programme incorporating ischemia-free liver transplantation in China

Background

In July 2017, the first affiliated hospital of Sun Yat-sen university carried out the world's first case of ischemia-free liver transplantation (IFLT). This study aimed to evaluate the performance of medical services pre- and post-IFLT implementation in the organ transplant department of this hospital based on diagnosis-related groups, so as to provide a data basis for the clinical practice of the organ transplant specialty.

Methods

The first pages of medical records of inpatients in the organ transplant department from 2016 to 2019 were collected. The China version Diagnosis-related groups (DRGs) were used as a risk adjustment tool to compare the income structure, service availability, service efficiency and service safety of the organ transplant department between the pre- and post-IFLT implementation periods.

Results

Income structure of the organ transplant department was more optimized in the post-IFLT period compared with that in the pre-IFLT period. Medical service performance parameters of the organ transplant department in the post-IFLT period were better than those in the pre-IFLT period. Specifically, case mix index values were 2.65 and 2.89 in the pre- and post-IFLT periods, respectively (p = 0.173). Proportions of organ transplantation cases were 14.16 and 18.27%, respectively (p < 0.001). Compared with that in the pre-IFLT period, the average postoperative hospital stay of liver transplants decreased by 11.40% (30.17 vs. 26.73 days, p = 0.006), and the average postoperative hospital stay of renal transplants decreased by 7.61% (25.23 vs.23.31 days, p = 0.092). Cost efficiency index decreased significantly compared with that in the pre-IFLT period (p < 0.001), while time efficiency index fluctuated around 0.83 in the pre- and post-IFLT periods (p = 0.725). Moreover, the average postoperative hospital stay of IFLT cases was significantly shorter than that of conventional liver transplant cases (p = 0.001).

Conclusion

The application of IFLT technology could contribute to improving the medical service performance of the organ transplant department. Meanwhile, the DRGs tool may help transplant departments to coordinate the future delivery planning of medical service.

Maternal and Neonatal Outcomes of Elective Induction of Labor at 39 or More Weeks: A Prospective, Observational Study

The purpose of our study is to compare the maternal and neonatal outcomes of induction of labor (IOL) versus expectant management at 39 weeks of gestation. We conducted a single-centered, prospective, observational study of nulliparous singleton women at 39 weeks or more. We compared the maternal and perinatal outcomes. Of 408 nulliparous women, 132 women were IOL group and 276 women were expectant management group. IOL and expectant group had similar cesarean delivery rate (18.2% vs. 15.9%, p = 0.570). The delivery time from admission was longer in IOL group (834 ± 527 vs. 717 ± 469 min, p = 0.040). The IOL group was less likely to have Apgar score at 5 min < 7 than in expectant group (0.8% vs. 5.4%, p = 0.023). Multivariate analysis showed that IOL at 39 weeks was not an independent risk factor for cesarean delivery (relative risk 0.64, 95% confidence interval: 0.28−1.45, p = 0.280). Maternal and neonatal adverse outcomes, including cesarean delivery rate, were similar to women in IOL at 39 weeks of gestation compared to expectant management in nulliparous women. IOL at 39 weeks of gestation could be recommended even when the indication of IOL is not definite.

REAL OPTIONS THEORY AND CLASSIFICATION OF PATIENTS BY DIAGNOSIS RELATED GROUPS: HOW THESE DIFFERENT FIELDS COULD RELATE?

ABSTRACT In a complex environment, the managers of hospital organizations should take hard decisions all the time. Therefore, tools and techniques, which seek to understand the past and project the future, are very important. In some situations, the complexity encountered requires the transfer of knowledge from other areas, to find solutions and develop tools that provide efficient management of resources. In this scenario, this article has the main objective to present a theoretical discussion that brings the relationship between the Theory of Real Options and the Diagnosis Related Groups, to identify possible points that underlie the use of real options in Diagnosis Related Groups. The results demonstrate that, with the patient's condition as the focus, both are applied in the hospital environment with the objective of supporting decision-making, but not together. In addition, the differences observed make the combination of some of its concepts relevant for decision-making.

Evidence-based nursing in the operating room of obstetrics and gynecology departments alleviates patients' adverse moods and improves their quality of life

OBJECTIVE

Operating room nursing is conducive to the smooth operation and the improvement of surgical outcomes. Clinically, evidence-based nursing (EBN) has gradually replaced routine nursing as it is tailored to meet the nursing needs of patients. This study mainly explored the effects of EBN in the operating room of the Obstetrics and Gynecology (O&G) Department on the relief of patients' adverse moods and improvement of their quality of life (QoL).

METHODS

This study enrolled 174 patients, including 88 patients who received routine nursing (control group) and 86 patients treated with EBN (observation group) in the operating room of the O&G Department of our hospital. Patients were assessed for psychological status, pain, nursing satisfaction, and QoL.

RESULTS

Compared with the control group, patients in the observation group showed significantly improved blood pressure and heart rate after care, as well as obviously decreased Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores. In addition, the postoperative pain in the observation group was significantly reduced compared with the control group. The nursing satisfaction was significantly higher in the observation group, as indicated by the nursing satisfaction survey. Also of note, the QoL of patients was significantly better in the observation group than that in the control group.

CONCLUSIONS

While relieving patients' adverse emotions and pain, the application of EBN in the operation room of the O&G Department can improve the satisfaction of patients towards nursing and bolster their QoL.

Analysis of the Effects of Electronic Medical Records and a Payment Scheme on the Length of Hospital Stay

Objectives: This study analyzed the effects of computerization of medical information systems and a hospital payment scheme on medical care outcomes. Specifically, we examined the effects of Electronic Medical Records (EMRs) and a diagnosis procedure combination/per-diem payment scheme (DPC/PDPS) on the average length of hospital stay (ALOS).Methods: Post-intervention changes in the monthly ALOS were measured using an interrupted time-series analysis.Results: The level changes observed in the monthly ALOS immediately post-DPC/PDPS were –1.942 (95% confidence interval [CI], –2.856 to –1.028), –1.885 (95% CI, –3.176 to –0.593), –1.581 (95% CI, –3.081 to –0.082) and –2.461 (95% CI, –3.817 to 1.105) days in all ages, <50, 50–64, and ≥65 years, respectively. During the post-DPC/PDPS period, trends of 0.107 (95% CI, 0.069 to 0.144), 0.048 (95% CI, –0.006 to 0.101), 0.183 (95% CI, 0.122 to 0.245) and 0.110 (95% CI, 0.054 to 0.167) days/month, respectively, were observed. During the post-EMR period, trends of –0.053 (95% CI, –0.080 to –0.027), –0.093 (95% CI, –0.135 to –0.052), and –0.049 (95% CI, –0.087 to –0.012) days/month were seen for all ages, 50–64 and ≥65 years, respectively.Conclusions: The increasing post-DPC/PDPS trends offset the decline in ALOS observed immediately post-DPC/PDPS, and the observed ALOS was longer than the counterfactual at the end of the DPC/PDPS study periods. Conversely, due to the downward trend seen after EMR introduction, the actual ALOS at the end of the EMR study period was shorter than the counterfactual, suggesting that EMRs might be more effective than the DPC/PDPS in sustainably reducing the LOS.

DeepDRG: Performance of Artificial Intelligence Model for Real-Time Prediction of Diagnosis-Related Groups

Nowadays, the use of diagnosis-related groups (DRGs) has been increased to claim reimbursement for inpatient care. The overall benefits of using DRGs depend upon the accuracy of clinical coding to obtain reasonable reimbursement. However, the selection of appropriate codes is always challenging and requires professional expertise. The rate of incorrect DRGs is always high due to the heavy workload, poor quality of documentation, and lack of computer assistance. We therefore developed deep learning (DL) models to predict the primary diagnosis for appropriate reimbursement and improving hospital performance. A dataset consisting of 81,486 patients with 128,105 episodes was used for model training and testing. Patients' age, sex, drugs, diseases, laboratory tests, procedures, and operation history were used as inputs to our multiclass prediction model. Gated recurrent unit (GRU) and artificial neural network (ANN) models were developed to predict 200 primary diagnoses. The performance of the DL models was measured by the area under the receiver operating curve, precision, recall, and F1 score. Of the two DL models, the GRU method, had the best performance in predicting the primary diagnosis (AUC: 0.99, precision: 83.2%, and recall: 66.0%). However, the performance of ANN model for DRGs prediction achieved AUC of 0.99 with a precision of 0.82 and recall of 0.57. The findings of our study show that DL algorithms, especially GRU, can be used to develop DRGs prediction models for identifying primary diagnosis accurately. DeepDRGs would help to claim appropriate financial incentives, enable proper utilization of medical resources, and improve hospital performance.

Payment mechanism and hospital admission: New evidence from Thailand healthcare reform

In 2007, Thailand's Civil Servant Medical Benefit Scheme (CSMBS), one of the three main public health insurers, adopted a new payment mechanism for hospital admission. There has been a shift from fee-for-service toward Diagnostic Related Group (DRG)-based payment that transfers financial risk from the government to health care providers. This study investigates the effects of this policy change on hospital admission, frequency of admission, length of stay (LOS), type of hospital admitted, and out-of-pocket (OOP) inpatient medical expenditure. By employing nationally representative micro-level data (Health and Welfare surveys) and difference-in-difference approach, this study finds a 1 percentage point decline in hospitalization, a 10% higher chance of admission at community hospitals (the lowest level inpatient public health care facility), and a 7% less chance of admission at higher level public health care facilities like general hospitals. No significant change was observed in LOS, frequency of admission, or OOP inpatient medical expenditure associated with the post-2007 payment mechanism change. Our results emphasize the effectiveness of a close-ended payment mechanism for health care in developing countries. This study also adds to the limited literature on using micro-level data to investigate payment mechanism change in the context of low- and middle-income countries.

Impacts of Diagnosis-Related Groups Payment on the Healthcare Providers' Behavior in China: A Cross-Sectional Study Among Physicians

Purpose

Currently, China is piloting diagnosis-related groups (DRG) payment system in 30 cities. The main aim of this study was to explore the respondents' impressions regarding the hospitals' policies and physicians' behavior change brought by the DRG payment system, and investigate whether and how the hospitals' policies affect the physicians' behavior.

Methods

We distributed questionnaires designed for this study to 200 physicians. Data analysis consisted of descriptive statistics, T-test, and network analysis.

Results

Respondents stated that the hospitals had adopted several policies in response to DRG payment and DRG payment could reduce overtreatment and improve efficiency. However, it also led to several negative effects including an increased explanation to the patients, hindering new technologies, case splitting, and cherry picking. In addition, there was no evidence that harmful effects such as refusing patients and premature discharge existed. Overall, the benefits outweighed the drawbacks of DRG. Moreover, the hospitals' policies could effectively change physician behaviors. Our results indicated that promoting the implementation of clinical pathways had the most positive impact, while limiting costs and length of stay is not recommended.

Conclusion

In general, Chinese physicians who participated in the questionnaire possessed relatively positive attitudes towards the DRG payment system. Nevertheless, some of the negative impacts cannot be ignored. Meanwhile, the hospitals' policies should be implemented with adequate consideration of the impact on physicians' behavior.

Visual impairment increases the risk of dementia, especially in young males in a 12-year longitudinal follow-up study of a national cohort

We investigated the effect of visual impairment (VI) on dementia development in a national cohort. In this 12-year nationwide population-based retrospective cohort study, national data were collected from National Health Insurance Cooperation of South Korea from 2002 to 2017, comprising 799,074 subjects selected from the dementia-free cohort representative of the Korean population. Crude hazard ratios (HRs) as well as age- and sex-adjusted HRs and confidence intervals (CIs) for the development of dementia were estimated using multivariable Cox regression models. VI significantly increased the risk of dementia with a HR of 2.726 (95% CI 2.251–3.300, p < 0.0001) after adjusting for age, sex, and interaction between age, sex, and VI. HR of interaction between VI and age for dementia was 0.539 (95% CI 0.436–0.667, p < 0.0001). In the sensitivity analysis after adjustment for age, sex, household income level, BMI and other comorbidities, VI showed higher risk for all the type of dementia (p < 0.0001). In subgroup analysis of VI, young males showed the highest risk for development of dementia with a HR of 2.687 (95% CI 2.219–3.254, p < 0.0001). VI significantly increased the risk of dementia in the study cohort, and young males with VI appeared to be the most susceptible to the development of dementia.

Analytical methods to assess the impacts of activity-based funding (ABF): a scoping review

BACKGROUND

Activity-Based Funding (ABF) has been implemented across many countries as a means to incentivise efficient hospital care delivery and resource use. Previous reviews have assessed the impact of ABF implementation on a range of outcomes across health systems. However, no comprehensive review of the methods used to generate this evidence has been undertaken. The aim of this review is to identify and assess the analytical methods employed in research on ABF hospital performance outcomes.

METHODS

We conducted a scoping review in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Five academic databases and reference lists of included studies were used to identify studies assessing the impact of ABF on hospital performance outcomes. Peer-reviewed quantitative studies published between 2000 and 2019 considering ABF implementation outside the U.S. were included. Qualitative studies, policy discussions and commentaries were excluded. Abstracts and full text studies were double screened to ensure consistency. All analytical approaches and their relative strengths and weaknesses were charted and summarised.

RESULTS

We identified 19 studies that assessed hospital performance outcomes from introduction of ABF in England, Korea, Norway, Portugal, Israel, the Netherlands, Canada, Italy, Japan, Belgium, China, and Austria. Quasi-experimental methods were used across most reviewed studies. The most commonly used assessment methods were different forms of interrupted time series analyses. Few studies used difference-in-differences or similar methods to compare outcome changes over time relative to comparator groups. The main hospital performance outcome measures examined were case numbers, length of stay, mortality and readmission.

CONCLUSIONS

Non-experimental study designs continue to be the most widely used method in the assessment of ABF impacts. Quasi-experimental approaches examining the impact of ABF implementation on outcomes relative to comparator groups not subject to the reform should be applied where possible to facilitate identification of effects. These approaches provide a more robust evidence-base for informing future financing reform and policy.

Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review

Payment mechanisms have attracted substantial research interest because of their consequent effect on care outcomes, including treatment costs, admission and readmission rates and patient satisfaction. Those mechanisms create the incentive environment within which health workers operate and can influence provider behaviour in ways that can facilitate achievement of national health policy goals. This systematic review aims to understand the effects of changes in hospital payment mechanisms introduced in low- and middle-income countries (LMICs) on hospital- and patient-level outcomes. A standardised search of seven databases and a manual search of the grey literature and reference lists of existing reviews were performed to identify relevant articles published between January 2000 and July 2019. We included original studies focused on hospital payment reforms and their effect on hospital and patient outcomes in LMICs. Narrative descriptions or studies focusing only on provider payments or primary care settings were excluded. The authors used the Risk of Bias in Non-Randomized Studies of Interventions tool to assess the risk of bias and quality. Results were synthesized in a narrative description due to methodological heterogeneity. A total of 24 articles from seven middle-income countries were included, the majority of which are from Asia. In most cases, hospital payment reforms included shifts from passive (fee-for-service) to active payment models-the most common being diagnosis-related group payments, capitation and global budget. In general, hospital payment reforms were associated with decreases in hospital expenditures, out-of-pocket payments, length of hospital stay and readmission rates. The majority of the articles scored low on quality due to weak study design. A shift from passive to active hospital payment methods in LMICs has been associated with lower hospital and patient costs as well as increased efficiency without any apparent compromise on quality. However, there is an important need for high-quality studies in this area.

A randomized controlled trial of ovarian reserve preservation and hemostasis during ovarian cystectomy

The preservation of ovarian reserve during laparoendoscopic single-site (LESS) ovarian cystectomy is crucial for reproductive-age women. This study was a single-blinded, single-center, and randomized controlled trial to evaluate the effect of hemostatic agents on the preservation of ovarian reserve and hemostasis during LESS ovarian cystectomy. Patients with unilateral ovarian cyst were randomized to the hemostatic agent and coagulation groups according to the hemostasis method. Afterwards, the patients underwent LESS ovarian cystectomy, and hemostasis was performed after ovarian cyst excision according to the assigned hemostasis method. If hemostasis was not completed within 10 min. After discharge, the patients were followed until 3 months after surgery. We compared the hemoglobin, anti-Müllerian hormone (AMH) levels, and ovarian volumes before surgery, and 2 days, 1 week, and 3 months after surgery (3 M-POST), and the decline ratio between the two groups. The decline ratio of serum AMH levels was greater at 3 M-POST in the coagulation than in the hemostatic agent group (median intention-to-treat [ITT], − 36.7 vs. − 13.3%; per-protocol [PP], − 36.8 vs. − 13.3%; P < 0.05). Notably, the difference of the decline ratio of serum AMH levels was only shown in endometriosis patients (median; ITT, − 50.7 vs. − 14.4%; PP, − 50.7% vs. − 14.4%; P < 0.05), while there was no difference in non-endometriosis patients. In conclusion, Hemostatic agents may be non-inferior to bipolar coagulation for preserving ovarian reserve and hemostasis during LESS ovarian cystectomy, in particular, for endometriosis patients. (Trial registry: ClinicalTrials.gov Identifier NCT03374397).

Comparison of treatment outcomes for native tissue repair and sacrocolpopexy as apical suspension procedures at the time of hysterectomy for uterine prolapse

Concomitant apical suspension should be performed at the time of hysterectomy for uterine prolapse to reduce the risk of recurrent prolapse. Native tissue repair (NTR) and sacrocolpopexy (SCP) are commonly used apical suspension procedures; however, it remains unclear which one is preferred. This study aimed to compare the treatment outcomes of NTR and SCP in terms of surgical failure, complication and reoperation rates. Surgical failure was defined as the presence of vaginal bulge symptoms, any prolapse beyond the hymen, or retreatment for prolapse. This retrospective cohort study included 523 patients who had undergone NTR (n = 272) or SCP (n = 251) along with hysterectomy for uterine prolapse and who had at least 4-month follow-up visits. During the median 3-year follow-up period, the surgical failure rate was higher in the NTR group (21.3% vs 6.4%, P < 0.01), with a low rate of retreatment in both groups. Overall complication rates were similar, but complications requiring surgical correction under anesthesia were more common in the SCP group (7.2% vs 0.4%, P < 0.01). As a result, the total reoperation rate was significantly higher in the SCP group (8.0% vs 2.6%, P = 0.02). Taken together, NTR may be a preferred option for apical suspension when hysterectomy is performed for uterine prolapse.

Characteristics and related factors of emergency department visits, readmission, and hospital transfers of inpatients under a DRG-based payment system: A nationwide cohort study

Objectives

Taiwan has implemented the Diagnosis Related Groups (DRGs) since 2010, and the quality of care under the DRG-Based Payment System is concerned. This study aimed to examine the characteristics, related factors, and time distribution of emergency department (ED) visits, readmission, and hospital transfers of inpatients under the DRG-Based Payment System for each Major Diagnostic Category (MDC).

Methods

We conducted a retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) from 2012 to 2013 in Taiwan. Multilevel logistic regression analysis was used to examine the factors related to ED visits, readmissions, and hospital transfers of patients under the DRG-Based Payment System.

Results

In this study, 103,779 inpatients were under the DRG-Based Payment System. Among these inpatients, 4.66% visited the ED within 14 days after their discharge. The factors associated with the increased risk of ED visits within 14 days included age, lower monthly salary, urbanization of residence area, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, Diseases and Disorders of the Kidney and Urinary Tract (MDC11) conferred the highest risk of ED visits within 14 days (OR = 4.95, 95% CI: 2.69–9.10). Of the inpatients, 6.97% were readmitted within 30 days. The factors associated with the increased risk of readmission included gender, age, lower monthly salary, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, the inpatients with Pregnancy, Childbirth and the Puerperium (MDC14) had the highest risk of readmission within 30 days (OR = 20.43, 95% CI: 13.32–31.34). Among the inpatients readmitted within 30 days, 75.05% of them were readmitted within 14 days. Only 0.16% of the inpatients were transferred to other hospitals.

Conclusion

The study shows a significant correlation between Major Diagnostic Categories in surgery and ED visits, readmission, and hospital transfers. The results suggested that the main reasons for the high risk may need further investigation for MDCs in ED visits, readmissions, and hospital transfers.

Effects of the new diagnosis-related group-based payment system and the increased incentive policy rates on the utilization rate of diagnostic laboratory test in Korea

A new diagnosis-related group (DRG) based payment system has been implemented in most public hospitals in Korea. We investigated the effects of the new DRG system and its incentive policy on the utilization rate of diagnostic laboratory tests. Three groups were categorized; 36 hospitals under the new DRG system (participant group), 72 hospitals (control-1) matching with 36 participants according to the number of beds, and 42 tertiary hospitals (control-2). The patients of acute myocardial infarction, cerebral infarction, type 2 diabetes mellitus, and gonarthrosis receiving total arthroplasty were included. We analyzed the mean length of stay and the number of diagnostic laboratory tests conducted during hospitalization of the three groups according to the new DRG system and the incentive policy rates under the new DRG system. Before participating in the new DRG system, the number of diagnostic laboratory tests in the participant group was less than that in the two control groups for all four diseases. However, although the participant group’s length of stay decreased under the new DRG system, the number of diagnostic laboratory tests increased as the maximum incentive policy rate increased. The increment of the number of diagnostic laboratory tests was prominent in the period of a maximum of 35% incentive policy rates. Finally, the number of diagnostic laboratory tests of the participant group was similar to or exceeded that of the control-2 group. The new DRG system’s incentive policy rates played a driving force on the increased utilization rate of the diagnostic laboratory test. For preparing in advance for the change in incentive policy rates, monitoring and guidelines for the utilization of diagnostic laboratory tests are necessary.

The New Diagnosis-Related Group Reimbursement System and Laboratory Test Quality in Korea: Analysis of External Quality Assessment Results

Korea introduced a new diagnosis-related group (NDRG), which is a mixed-bundle reimbursement system. We evaluated the effects of NDRGs on laboratory test quality by analyzing data over three years (2016-2018) from the Korean Association of External Quality Assessment Service (KEQAS). A total of 42 NDRG-participating hospitals (CASE), 84 non-participating similar size-hospitals (CON-1), and 42 tertiary hospitals (CON-2) were included. We assumed the proportion of KEQAS results with a larger than 2 standard deviation index (SDI) to be a bad laboratory quality marker (BLQM). CASE BLQMs were lower than CON-1 BLQMs for more than 2 years in alkaline phosphatase (ALP), alanine aminotransferase (ALT), chloride, glucose, sodium, and total protein, and higher in creatinine. CASE BLQMs were higher than CON-2 BLQMs for more than 2 years in ALP, chloride, creatinine, glucose, lactate dehydrogenase (LDH), phosphorus, potassium, sodium, total calcium, total cholesterol, triglyceride, and uric acid. Mean SDIs for general chemistry tests were not significantly different depending on NDRG participation. However, the NDRG is currently a pilot program that compensates the amount of each institution's reimbursement based on the fee-for-service system, and most participants were public hospitals. Thus, the effects of NDRGs on laboratory test quality should be re-evaluated after the NDRG program has stabilized and more private hospitals are participating.

Effects of a mandatory DRG payment system in South Korea: Analysis of multi-year nationwide hospital claims data

Background

In 2002, a voluntary diagnosis-related groups (DRGs) payment system was introduced in South Korea for seven disease groups, and participation in the DRGs was mandated for all hospitals beginning in 2013. The primary aim of this study was to compare results reflective of patient care between voluntary participation hospitals (VPHs) and mandatory participation hospitals (MPHs) governed by either the DRGs or fee-for-service (FFS) payment system.

Methods

We collected DRGs and FFS inpatient records (n=3,038,006) from the Health Insurance Review and Assessment for the period of July 2011 to July 2014 and compared length-of-stay, total medical costs, shifting services to an outpatient setting, and readmission rates according to payment system, time of DRGs implementation, and hospital type. We analyzed the effects of mandatory introduction in DRGs payment system on results for patient care and used generalized estimating equations with difference-in-difference methodology.

Results

Most notably, patients at MPHs had significantly shorter LOS and lower readmission rates than VPH patients after mandatory introduction of the DRGs. Shifting services to an outpatient setting was similar between the groups.

Conclusions

Our findings suggest that the DRGs payment policy in Korea has decreased LOS and readmission rates. These findings support the continued implementation and enlargement of the DRGs payment system for other diseases in South Korea, given its potential for curbing unnecessary resource usage encouraged by FFS. If the Korean government deliberates on expansion of the DRGs to include other diseases with higher rates of complications, policymakers need to monitor deterioration of health care quality caused by fixed pricing.

Detecting hospital behaviors of up-coding on DRGs using Rasch model of continuous variables and online cloud computing in Taiwan

BACKGROUND

This work aims to apply data-detection algorithms to predict the possible deductions of reimbursement from Taiwan's Bureau of National Health Insurance (BNHI), and to design an online dashboard to send alerts and reminders to physicians after completing their patient discharge summaries.

METHODS

Reimbursement data for discharged patients were extracted from a Taiwan medical center in 2016. Using the Rasch model of continuous variables, we applied standardized residual analyses to 20 sets of norm-referenced diagnosis-related group (DRGs), each with 300 cases, and compared these to 194 cases with deducted records from the BNHI. We then examine whether the results of prediction using the Rasch model have a high probability associated with the deducted cases. Furthermore, an online dashboard was designed for use in the online monitoring of possible deductions on fee items in medical settings.

RESULTS

The results show that 1) the effects deducted by the NHRI can be predicted with an accuracy rate of 0.82 using the standardized residual approach of the Rasch model; 2) the accuracies for drug, medical material and examination fees are not associated among different years, and all of those areas under the ROC curve (AUC) are significantly greater than the randomized probability of 0.50; and 3) the online dashboard showing the possible deductions on fee items can be used by hospitals in the future.

CONCLUSION

The DRG-based comparisons in the possible deductions on medical fees, along with the algorithm based on Rasch modeling, can be a complementary tool in upgrading the efficiency and accuracy in processing medical fee applications in the discernable future.

Factors associated with the length of hospital stay of women undergoing cesarean section

OBJECTIVE

To evaluate whether age group, complications or comorbidities are associated with the length of hospitalization of women undergoing cesarean section.

METHODS

A cross-sectional study was carried out between June 2012 and July 2017, with 64,437 women undergoing cesarean section and who did not acquire conditions during their hospital stay. Hospital discharge data were collected from national health institutions, using the Diagnosis-Related Groups system (DRG Brasil®). The DRG referring to cesarean section with additional complications or comorbidities (DRG 765) and cesarean section without complications or associated comorbidities (DRG 766) were included in the initial diagnosis. The influence of age group and comorbidities or complications present at admission on the length of hospital stay was assessed based on the means of the analysis of variance. The size of the effect was verified by Cohen’s D, which allows evaluating clinical relevance. The criticality levels were identified using the Duncan test.

RESULTS

The longest length of hospital stay was observed in the age group from 15 to 17 years old and among those aged 45 years old or more. The hospital stay of women with complications or comorbidities at the time of admission was also longer. Moreover, it was noted that the increase in criticality level was associated with an increase in the mean length of hospital stay.

CONCLUSIONS

The length of hospital stay of women is higher among those belonging to the age group ranging from 15 to 17 years old and for those aged 45 years old or more. The presence of associated comorbidities, such as eclampsia, pre-existing hypertensive disorder with superimposed proteinuria and gestational hypertension (induced by pregnancy) with significant proteinuria increase the length of hospital stay. This study enabled the construction of distinct criticality level profiles based on the combination of age groups and the main comorbidities, which were directly related to the length of hospital stay.

The effect of diagnosis-related group payment system on the quality of medical care for pelvic organ prolapse in Korean tertiary hospitals

PURPOSE

To assess changes in clinical practice patterns after implementing diagnosis-related group (DRG) payment system in July 2013 and its effect on the quality of care for pelvic organ prolapse (POP).

MATERIALS AND METHODS

Using the 2011-2016 administrative database from National Health Insurance claim data, we reviewed medical information of 7362 patients who underwent hysterectomies for POP in Korean tertiary hospitals. We compared changes in several variables including length of stay, concomitant procedures, outpatient visits and readmission within 30 days after discharge, and retreatment for POP or stress urinary incontinence within postoperative 1 year before and after DRG system.

RESULTS

After the introduction of DRG system, the average length of stay decreased (7.74 ± 2.88 to 6.63 ± 2.18 days, p<0.001) without increasing readmission rates. However, the number of outpatient visits increased (2.78±2.33 to 2.98±2.47, p<0.001). Regarding concomitant procedures, the rates of colpopexy and midurethral slings significantly decreased (7.87% and 9.84% to 4.93% and 2.93%, respectively, all p<0.001). Even though there was no difference in the reoperation rates, pessary insertion for recurrent POP significantly increased after the introduction of DRG system (0.10% to 0.38%, p = 0.015).

CONCLUSION

The implementation of DRG in Korean tertiary hospitals has led to increase of outpatient visits and reduced surgical management for POP, which indicates that the uniform application of DRG influences the quality of care for POP patients.