The effects of diagnosis-related groups payment on hospital healthcare in China: a systematic review

Uptake of biosimilars in China: a retrospective analysis of the case of trastuzumab from 2018 to 2023

BACKGROUND

The Chinese biosimilar industry has demonstrated rapid growth in recent years. Limited evidence is available about biosimilar uptake at the national level. This study aimed to assess biosimilar uptake in the case of trastuzumab and to explore potential factors influencing the biosimilar penetration at national and provincial levels.

METHODS

This study employed an interrupted time series analysis to assess the level and trend changes of national trastuzumab originator consumption and the overall trastuzumab consumption after the price reduction of the originator and the introduction of the first biosimilar using the China Hospital Pharmacy Audit procurement data from March 2018 to February 2023. A latent class trajectory model (LCTM) was also adopted to estimate the biosimilar penetration across 30 provincial-level administrative divisions (PLADs). Based on the LCTM grouping results, provincial characteristics were analyzed.

RESULTS

After rapid growth, the penetration of biosimilars demonstrated a moderate ascending trend at the national level, reaching 27% in February 2023. Following the introduction of the first biosimilar in July 2021, the consumption of the originator decreased by 0.5% per month (P = 0.008), and the growth rate of overall trastuzumab consumption decreased by 1.1% per month (P = 0.014). LCTM fit the best when the number of trajectory classes was two, dividing 30 PLADs into a group demonstrating a faster increase in biosimilar penetration and the other with a slower increase. The PLADs in the fast-increasing group had a higher proportion of the population covered by the national basic health insurance, a lower proportion of the urban population, a lower proportion of the population covered by the urban employee health insurance program, a lower gross domestic product per capita, a lower total health expenditure per capita, and a lower out-of-pocket expenditure.

CONCLUSIONS

The uptake of trastuzumab biosimilars in China was lower compared with major European countries. The introduction of trastuzumab biosimilars presented a substitutional effect. Perceptions of physicians and patients, the medicines procurement model, competition from other biologics, and health insurance payment methods may influence biosimilar uptake. Enhancing a comprehensive understanding of biosimilars among physicians and patients, including biologics with biosimilars in the national pooled procurement, and implementing provider payment reforms could foster biosimilar penetration.

Does the Diagnosis-Intervention Packet Payment Reform Impact Medical Costs, Quality, and Medical Service Capacity in Secondary and Tertiary Hospitals? A Difference-in-Differences Analysis Based on a Province in Northwest China

Purpose

To control medical costs and regulate the behavior of providers, China has formed an original widely piloted case-based payment under the regional global budget, called the Diagnosis-Intervention Packet (DIP). This study aimed to evaluated the impact of the DIP payment reform on medical costs, quality of care, and medical service capacity in a less-developed pilot city in Northwest China.

Patients and Methods

We used the de-identified case-level discharge data of hospitalized patients from January 2021 to June 2022 in pilot and control cities located in the same province. We performed difference-in-differences (DID) analysis to examine the differential impact of the DIP reform for the entire sample and between secondary and tertiary hospitals.

Results

The DIP payment reform resulted in a significant decrease of total expenditure per case in the entire sample (5.5%, P < 0.01) and tertiary hospitals (9.3%, P < 0.01). In-hospital mortality rate decreased significantly in tertiary hospitals (negligible in size, P < 0.05), as did all-cause readmission rate within 30 days in the entire sample (1.1 percentage points, P < 0.01) and secondary hospitals (1.4 percentage points, P < 0.01). Proportion of severe patients increased significantly in the entire sample (1.2 percentage points, P < 0.05) and tertiary hospitals (2.5 percentage points, P < 0.01). We did not find the DIP reform was associated with a significant change in relative weight per case.

Conclusion

The DIP payment reform in the less-developed pilot city achieved short-term success in controlling medical costs without sacrificing the quality of care for the entire sample. Compared with secondary hospitals, tertiary hospitals experienced a greater decline in medical costs and received more severe patients. These findings hold lessons for less developed countries or areas to implement case-based payments and remind them of the variations between different levels of hospitals.

Unraveling the effects of DIP payment reform on inpatient healthcare: insights into impacts and challenges

BACKGROUND

The Diagnosis-Intervention Packet (DIP) payment system, initiated by China's National Healthcare Security Administration, is designed to enhance healthcare efficiency and manage rising healthcare costs. This study aims to evaluate the impact of the DIP payment reform on inpatient care in a specialized obstetrics and gynecology hospital, with a focus on its implications for various patient groups.

METHODS

To assess the DIP policy's effects, we employed the Difference-in-Differences (DID) approach. This method was used to analyze changes in total hospital costs and Length of Stay (LOS) across different patient groups, particularly within select DIP categories. The study involved a comprehensive examination of the DIP policy's influence pre- and post-implementation.

RESULTS

Our findings indicate that the implementation of the DIP policy led to a significant increase in both total costs and LOS for the insured group relative to the self-paying group. The study further identified variations within DIP groups both before and after the reform. In-depth analysis of specific disease groups revealed that the insured group experienced notably higher total costs and LOS compared to the self-paying group.

CONCLUSIONS

The DIP reform has led to several challenges, including upcoding and diagnostic ambiguity, because of the pursuit of higher reimbursements. These findings underscore the necessity for continuous improvement of the DIP payment system to effectively tackle these challenges and optimize healthcare delivery and cost management.

A study of pharmacists-joint total parenteral nutrition in haematopoietic cell transplantation in accord with diagnosis related groups: A retrospective clinical research

Background

Within Diagnosis Related Groups, based on service capability, efficiency, and quality safety assessment, clinical pharmacists contribute to promoting rational drug utilisation in healthcare institutions. However, a deficiency of pharmacist involvement has been observed in the total parenteral nutrition support to patients following haematopoietic cell transplantation (HCT) within DRGs.

Methods

This study involved 146 patients who underwent HCT at the Department of Haematology, the Second Affiliated Hospital of Dalian Medical University, spanning from January 2020 to December 2022.

Results

Patients were allocated equally, with 73 in the control group and 73 in the pharmacist-involved group: baseline characteristics showed no statistics significance, including age, body mass index, nutrition risk screening-2002 score, liver and kidney function, etc. Albumin levels, prealbumin levels were significantly improved after a 7-day TPN support (34.92 ± 4.24 vs 36.25 ± 3.65, P = 0.044; 251.30 ± 95.72 vs 284.73 ± 83.15, P = 0.026). The body weight was increased after a 7-day support and before discharge (58.77 ± 12.47 vs 63.82 ± 11.70, P = 0.013; 57.61 ± 11.85 vs 64.92 ± 11.71, P < 0.001). The length of hospital stay, costs and the rate of re-admissions were significantly shortened (51.10 ± 1.42 vs 46.41 ± 1.86, P = 0.048; 360,162.67 ± 91,831.34 vs 324,070.16 ± 112,315.51, P = 0.035; 61.64% vs 43.84%, P = 0.046).

Conclusions

Pharmacist-joint TPN support enhances the service efficiency score of medical units, ensuring the fulfilment of orders and rational medication.

Exploring hot topics and evolutionary paths in the Diagnosis-Related Groups (DRGs) field: a comparative study using LDA modeling

BACKGROUND

This study reviews the research status of Diagnosis-related groups (DRGs) payment system in China and globally by analyzing topical issues in this field and exploring the evolutionary trends of DRGs in different developmental stages.

METHODS

Abstracts of relevant literature in the field of DRGs were extracted from the China National Knowledge Infrastructure (CNKI) database and the Web of Science (WoS) core database and used as text data. A probabilistic distribution-based Latent Dirichlet Allocation (LDA) topic model was applied to mine the text topics. Topical issues were determined by topic intensity, and the cosine similarity of the topics in adjacent stages was calculated to analyze the topic evolution trend.

RESULTS

A total of 6,758 English articles and 3,321 Chinese articles were included. Foreign research on DRGs focuses on grouping optimization, implementation effects, and influencing factors, whereas research topics in China focus on grouping and payment mechanism establishment, medical cost change evaluation, medical quality control, and performance management reform exploration.

CONCLUSIONS

Currently, the field of DRGs in China is developing rapidly and attracting deepening research. However, the implementation depth of research in China remains insufficient compared with the in-depth research conducted abroad.

Impacts of DRG-Based Prepayment Reform on the Cost and Quality of Patients with Neurologic Disorders: Evidence from a Quasi-Experimental Analysis in Beijing, China

Purpose

As one of the pioneering pilot cities in China's extensive Diagnosis Related Groups (DRG) -based prepayment reform, Beijing is leading a comprehensive overhaul of the prepayment system, encompassing hospitals of varying affiliations and tiers. This systematic transformation is rooted in extensive patient group data, with the commencement of actual payments on March 15, 2022. This study aims to evaluate the effectiveness of DRG payment reform by examining how it affects the cost, volume, and utilization of care for patients with neurological disorders.

Patients and Methods

Utilizing the exogenous shock resulting from the implementation of the DRG-based prepayment system, we adopted the Difference-in-Differences (DID) approach to discern changes in outcome variables among DRG payment cases, in comparison to control cases, both before and following the enactment of the DRG policy. The analytical dataset was derived from patients diagnosed with neurological disorders across all hospitals in Beijing that underwent the DRG-based prepayment reform. Strict data inclusion and exclusion criteria, including reasonableness tests, were applied, defining the pre-reform timeframe as March 15th through October 31st, 2021, and the post-reform timeframe as the corresponding period in 2022. The extensive dataset encompassed 53 hospitals and encompassed hundreds of thousands of cases.

Results

The implementation of DRG-based prepayment resulted in a substantial 12.6% decrease in total costs per case and a reduction of 0.96 days in length of stay. Additionally, the reform was correlated with significant reductions in overall in-hospital mortality and readmission rates. Surprisingly, the study unearthed unintended consequences, including a significant reduction in the proportion of inpatient cases classified as surgical patients and the Case Mix Index (CMI), indicating potential strategic adjustments by providers in response to the introduction of DRG payments.

Conclusion

The DRG payment reform demonstrates substantial effects in restraining cost escalation and enhancing quality. Nevertheless, caution must be exercised to mitigate potential issues such as patient selection bias and upcoding.

Cost prediction for ischemic heart disease hospitalization: Interpretable feature extraction using network analysis

OBJECTIVES

Ischemic heart disease (IHD) is a significant contributor to global mortality and disability, imposing a substantial social and economic burden on individuals and healthcare systems. To enhance the efficient allocation of medical resources and ultimately benefit a larger population, accurate prediction of healthcare costs is crucial.

METHODS

We developed an interpretable IHD hospitalization cost prediction model that integrates network analysis with machine learning. Specifically, our network-enhanced model extracts explainable features by leveraging a diagnosis-procedure concurrence network and advanced graph kernel techniques, facilitating the capture of intricate relationships between medical codes.

RESULTS

The proposed model achieved an R2 of 0.804 ± 0.008 and a root mean square error (RMSE) of 17,076 ± 420 CNY on the temporal validation dataset, demonstrating comparable performance to the model employing less interpretable code embedding features (R2: 0.800 ± 0.008; RMSE: 17,279 ± 437 CNY) and the hybrid graph isomorphism network (R2: 0.802 ± 0.007; RMSE: 17,249 ± 387 CNY). The interpretation of the network-enhanced model assisted in pinpointing specific diagnoses and procedures associated with higher hospitalization costs, including acute kidney injury, permanent atrial fibrillation, intra-aortic balloon bump, and temporary pacemaker placement, among others.

CONCLUSION

Our analysis results demonstrate that the proposed model strikes a balance between predictive accuracy and interpretability. It aids in identifying specific diagnoses and procedures associated with higher hospitalization costs, underscoring its potential to support intelligent management of IHD.

Development of an assessment tool for designated medical institutions in China--Based on the application of an online assessment system

Background

Due to the expanding coverage of medical insurance and the growth of medical expenses, the ability to assess the performance of designated medical institutions (DMIs) in supporting the delivery of high-quality patient care and the standardized use of funds represents a priority in China. Despite such interest, there has yet to be an operable standard and labor-saving method for assessing DMIs in China.

Objective

The main objectives include two aspects: (1) establishing an evaluation index system for DMIs based on contracts; (2) designing and developing an online evaluation platform.

Methods

A group of 20 experts with theoretical and practical expertise in medical insurance regulation and performance evaluation were invited to select available indicators. A combination weighting method based on analytic hierarchy process and entropy method was used to determine the weight coefficient. Shanghai was taken as the sample area, and 760 DMIs were included in the empirical research. The test-retest reliability method and criterion-related validity method was used to test the reliability and the validity of the evaluation result.

Results

An assessment index system that included 6 domains and 56 indicators was established in this study. Furthermore, we developed an online platform to assist in the implementation of the assessment. The results showed that the average score of assessment was 94.39, the median was 96.92. The test-retest reliability value was 0.96 (P ≤ 0.01), which indicated high stability of the assessment. In addition, there was a significant negative relationship between assessment score and the penalty amount of DMIs (R = -0.133, P < 0.001). After adjusting for the basic characteristics of medical institutions, the number of visits and revenue, the negative relationship was still significant (B = -0.080, P < 0.05). These results are consistent with expectations, indicating that the assessment had good criterion-related validity.

Conclusions

This study established an operable assessment measure and developed an online platform to assess the performance of DMIs. The results showed good feasibility and reliability in empirical research. Our research findings provided an operable Chinese solution for DMI assessment that saves manpower and time, which would have good enlightening significance in other regions of China and in low-income and middle-income countries internationally.

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.

Optimization of Diagnosis-Related Groups for 14,246 Patients with Uterine Leiomyoma in a Single Center in Western China Using a Machine Learning Model

Background

Uterine leiomyoma (UL) is one of the most common benign tumors in women, and its incidence is gradually increasing in China. The clinical complications of UL have a negative impact on women's health, and the cost of treatment poses a significant burden on patients. Diagnosis-related groups (DRG) are internationally recognized as advanced healthcare payment management methods that can effectively reduce costs. However, there are variations in the design and grouping rules of DRG policies across different regions. Therefore, this study aims to analyze the factors influencing the hospitalization costs of patients with UL and optimize the design of DRG grouping schemes to provide insights for the development of localized DRG grouping policies.

Methods

The Mann-Whitney U-test or the Kruskal-Wallis H-test was employed for univariate analysis, and multiple stepwise linear regression analysis was utilized to identify the primary influencing factors of hospitalization costs for UL. Case combination classification was conducted using the exhaustive chi-square automatic interactive detection (E-CHAID) algorithm within a decision tree framework.

Results

Age, occupation, number of hospitalizations, type of medical insurance, Transfer to other departments, length of stay (LOS), type of UL, admission condition, comorbidities and complications, type of primary procedure, other types of surgical procedures, and discharge method had a significant impact on hospitalization costs (P<0.05). Among them, the type of primary procedure, other types of surgical procedures, and LOS were the main factors influencing hospitalization costs. By incorporating the type of primary procedure, other types of surgical procedures, and LOS into the decision tree model, patients were divided into 11 DRG combinations.

Conclusion

Hospitalization costs for UL are mainly related to the type of primary procedure, other types of surgical procedures, and LOS. The DRG case combinations of UL based on E-CHAID algorithm are scientific and reasonable.

Current scenario and challenges of clinical pharmacists to implement pharmaceutical care in DRG/DIP payment hospitals in China: a qualitative interview study

Purpose

The Diagnosis-Related Group (DRG) or Diagnosis-Intervention Packet (DIP) payment system, now introduced in China, intends to streamline healthcare billing practices. However, its implications for clinical pharmacists, pivotal stakeholders in the healthcare system, remain inadequately explored. This study sought to assess the perceptions, challenges, and roles of clinical pharmacists in China following the introduction of the DRG or DIP payment system.

Methods

Qualitative interviews were conducted among a sample of clinical pharmacists. Ten semi-structured interviews were conducted, either online or face to face. Thematic analysis was employed to identify key insights and concerns related to their professional landscape under the DRG or DIP system.

Results

Clinical pharmacists exhibited variable awareness levels about the DRG or DIP system. Their roles have undergone shifts, creating a balance between traditional responsibilities and new obligations dictated by the DRG or DIP system. Professional development, particularly concerning health economics and DRG-based or DIP-based patient care, was highlighted as a key need. There were calls for policy support at both healthcare and national levels and a revised, holistic performance assessment system. The demand for more resources, be it in training platforms or personnel, was a recurrent theme.

Conclusion

The DRG or DIP system's introduction in China poses both opportunities and challenges for clinical pharmacists. Addressing awareness gaps, offering robust policy support, ensuring adequate resource allocation, and recognizing the evolving role of pharmacists are crucial for harmoniously integrating the DRG or DIP system into the Chinese healthcare paradigm.

Designing a model for implementing diagnosis-related groups in Iran: An action plan approach

Background and Aims

Implementing diagnosis-related groups (DRGs) in different countries increases the efficiency of healthcare services, improves treatment quality, and reduces treatment costs. Due to the lack of a coherent model for its implementation, the present study aimed to develop a DRGs-based implementation action plan Model for Iran.

Methods

The present study was an applied, descriptive cross-sectional study conducted in three stages. In the first stage, a review of studies conducted in different countries was carried out. In the second stage, a model was designed for an action plan to implement the DRGs in Iran. In the third stage, the model was validated based on the Delphi technique.

Results

The DRGs-based implementation action plan model in Iran was designed in three primary axes, including the strategic approach of the DRGs-based implementation action plan, technical dimensions, and executive institutions involved in the DRGs-based implementation action plan. Validation of the designed model showed the agreement of experts (94%) for the mentioned axes.

Conclusion

The significance of tailoring a DRGs-based implementation action plan to each country's unique context is well-established. Given the intricacies of the Iranian healthcare system, we recommend an initial pilot implementation of DRGs at the hospital level, followed by a gradual national rollout.

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.

A decision tree-based study of pulmonary tuberculosis diagnosis-related groups

BACKGROUND

Globally, pulmonary tuberculosis is a significant public health and social problem.

OBJECTIVE

We investigated the factors influencing the hospitalization cost of patients with pulmonary tuberculosis and grouped cases based on a decision tree model to provide a reference for enhancing the management of diagnosis-related groups (DRGs) of this disease.

METHODS

The data on the first page of the medical records of patients with the primary diagnosis of pulmonary tuberculosis were extracted from the designated tuberculosis hospital. The influencing factors of hospitalization cost were determined using the Wilcoxon rank sum test and multiple linear stepwise regression analysis, and the included cases were grouped using the chi-squared automated interaction test decision tree model, with these influential factors used as classification nodes. In addition, the included cases were grouped according to the ZJ-DRG grouping scheme piloted in Zhejiang Province, and the differences between the two grouping methods were compared.

RESULTS

The length of hospital stay, respiratory failure, sex, and age were the determining factors of the hospitalization cost of patients with pulmonary tuberculosis, and these factors were incorporated into the decision tree model to form eight case combinations. The reduction in variance (RIV) using this grouping method was 60.60%, the heterogeneity between groups was high, the coefficients of variance ranged from 0.29 to 0.47, and the intra-group difference was small. The patients were also divided into four groups based on the ZJ-DRG grouping scheme piloted in Zhejiang Province. The RIV using this grouping method was 55.24, the differences between groups were acceptable, the coefficients of variance were 1.00, 0.61, 0.77, and 0.87, respectively, and the intra-group difference was significant.

CONCLUSION

When the pulmonary tuberculosis cases were grouped according to the duration of hospital stay, respiratory failure, and age, the results were rather reasonable, providing a reference for DRG management and cost control of this disease.

County Hospital Responses to Funding Reforms in Zhejiang, China: An Interrupted Time-Series Analysis

This study aimed to assess the effects of a two-stage funding reform, involving DRGs-based (Diagnostic Related Groups) payments for inpatient care and capitation funding for outpatient care, respectively, on services volume and care expenditure of county hospitals in Zhejiang province, China. A quasi-experimental design was adopted, involving 6 hospitals from 2 counties in the intervention group and 12 hospitals from 5 counties in the control group. The DRGs-based payments for inpatient care and capitation funding for outpatient care were introduced in January 2018 and January 2019, respectively. Controlled interrupted time-series analyses were performed to determine the effects of the funding reforms using monthly data over the period from January 2017 to December 2019. The volume of inpatient care decreased after the introduction of the first-stage DRGs-based payments, which was accompanied by an increase in the volume of outpatient visits. The DRGs-based payments led to a reduction of on average 1390 Yuan total expenditure per episode of inpatient care and 1116 Yuan out-of-pocket (OOP) payment per episode of inpatient care. However, the average outpatient expenditure per visit increased. So did the corresponding OOP payment per outpatient visit. The introduction of the second-stage capitation funding for outpatient care reversed the increasing trend of outpatient care. The average expenditure and OOP payment per outpatient visit decreased. The funding reforms create a significant effect on service volumes and expenditures in county hospitals. A coordinated approach to both inpatient and outpatient funding mechanisms is needed to minimize cost-shifting between inpatient and outpatient care and to achieve the intended policy outcomes.

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.

Construction and application of a nursing human resource allocation model based on the case mix index

BACKGROUND

The case mix index (CMI) may reflect the severity of disease and the difficulty of care objectively, and is expected to be an ideal indicator for assessing the nursing workload. The purpose of this study was to explore the quantitative relationship between daily nursing worktime (DNW) and CMI to provide a method for the rational allocation of nursing human resources.

METHODS

Two hundred and seventy-one inpatients and 36 nurses of the department of hepatobiliary surgery were prospectively included consecutively from August to September 2022. The DNW of each patient were accurately measured, and the CMI data of each patient were extracted. Among 10 curve estimations, the optimal quantitative model was selected for constructing the nursing human resource allocation model. Finally, the applicability of the allocation model was preliminarily assessed by analyzing the relationship between the relative gap in nursing human resources and patient satisfaction, as well as the incidence of adverse events in 17 clinical departments.

RESULTS

The median (P25, P75) CMI of the 271 inpatients was 2.62 (0.92, 4.07), which varied by disease type (F = 3028.456, P < 0.001), but not by patient gender (F = 0.481, P = 0.488), age (F = 2.922, P = 0.089), or level of care (F = 0.096, P = 0.757). The median (P25, P75) direct and indirect DNW were 76.07 (57.98, 98.85) min and 43.42 (39.42, 46.72) min, respectively. Among the 10 bivariate models, the quadratic model established the optimal quantitative relationship between CMI and DNW; DNW = 92.3 + 4.8*CMI + 2.4*CMI2 (R2 = 0.627, F = 225.1, p < 0.001). The relative gap between theoretical and actual nurse staffing in the 17 clinical departments were linearly associated with both patient satisfaction (r = 0.653, P = 0.006) and incidence of adverse events (r = - 0.567, P = 0.021). However, after adjusting for other factors, it was partially correlated only with patient satisfaction (rpartial = 0.636, P = 0.026).

CONCLUSION

The DNW derived from CMI can be used to allocate nursing human resources in a rational and convenient way, improving patient satisfaction while ensuring quality and safety.

The impact of DRG on resource consumption of inpatient with ischemic stroke

Background

Diagnosis-related group (DRG) payments were gradually introduced and used in 12 public hospitals in L city. Given the high incidence and burden of ischemic stroke, the study aimed to assess the impact of DRG payment reform on inpatient medical resource utilization.

Methods

Data were obtained from the DRG local database of the new Chinese cooperative medical program in L city. The study used interrupted time series analysis to examine changes in length of stay and medical costs before and after the reform, and also assessed changes in different subgroups.

Results

There were 763 and 4,731 ischemic stroke patients in tertiary hospitals and 1953 and 10,439 patients in secondary hospitals before and after the DRG payment reform, respectively. After the reform, LOS was reduced 0.047 and 0.47 days in tertiary and secondary hospitals, respectively. Medical expenses decreased by 30.189 yuan in tertiary hospitals, but those increased by 44.918 yuan in secondary hospitals monthly. For gender, the average LOS reduced by 0.462 and 0.471 days for male and female in secondary hospitals. The change in medical expenses for male patients in tertiary hospitals and female in secondary hospitals were more significant, with a decrease of 65.396 yuan and increase of 56.257 yuan. The most pronounced change in resource consumption was seen for patients aged 85 years and older, with an increase in average LOS and medical expenses by 0.394 days and 382.422 yuan in tertiary hospitals. They showed a reduction in the average LOS by 1.480 days, and increase in the average medical expenses by 133.485 yuan in secondary hospitals monthly. Regarding disease severity, the most significant changes were seen in MCC patients. The average LOS decreased by 0.197 and 0.928 days and the average medical expenses decreased by 131.526 and 21.631 yuan in tertiary and secondary hospitals, respectively.

Conclusion

The implementation of DRG payment system has led to a reduction in the LOS in various levels of hospitals, which would save in bed resources. However, DRG payment reform can help to control medical expenses for ultra-high cases, but it may not be useful to control the overall increase in medical expenses.

Application of problem based learning (PBL) and case based learning (CBL) in the teaching of international classification of diseases encoding

To study the application of PBL combined with CBL teaching mode in the teaching of international classification of diseases (ICD) encoding, so as to improve students' grasp of ICD encoding knowledge. From March 2020 to June 2020, 50 students majoring in health information management who were interns in a Grade A general hospital were selected as the research participants and randomly divided into experimental group and control group, 25 in each group. The experimental group and the control group adopted the PBL combined CBL teaching mode and the traditional teaching mode respectively to carry out the classification and coding teaching. The academic achievement of the two groups of students was evaluated by means of achievement assessment and questionnaire survey based on information processing theory. The scores of theoretical knowledge in the experimental group and the control group were 79.78 ± 8.55 and 70.92 ± 10.81, respectively, and the scores of skill operation in the two groups were 79.76 ± 8.28 and 70.00 ± 10.41, respectively. The test scores of the experimental group were higher than those of the control group, and the difference was statistically significant (P < 0.05). The scores of knowledge acquisition ability of experimental group and control group were 16.72 ± 1.79 and 16.60 ± 2.36, the scores of knowledge sharing ability were 24.20 ± 2.61 and 21.00 ± 2.65, the scores of knowledge storage ability were 20.80 ± 2.47 and 17.24 ± 4.90, respectively. The scores of knowledge application ability were 14.00 ± 1.80 and 11.00 ± 2.69, the scores of knowledge innovation ability were 20.16 ± 2.34 and 18.08 ± 3.70, and the total scores were 95.88 ± 6.08 and 83.92 ± 11.30, respectively. The scores of all questionnaires in the experimental group were higher than those in the control group. The scores of knowledge sharing ability, knowledge storage ability, knowledge application ability, knowledge innovation ability and total score between the two groups were higher than those of the control group, and the differences were statistically significant (P < 0.05). PBL combined with CBL teaching model has good academic achievement in ICD encoding teaching, which can significantly improve academic performance and learning ability, and is worthy of promotion.

Flexible ureteroscopy under local anesthesia for stone management: initial exploration and two-year experience

BACKGROUND

Flexible ureteroscopy (f-URS) is a minimally invasive surgical technique used for treating urinary tract stones. While general anesthesia (GA) is the standard method used, it comes with risks. Local anesthesia (LA) is a safer and more cost-effective alternative to GA, and its use in f-URS could potentially reduce patients' risks and increase accessibility to treatment. This study aims to investigate the feasibility, safety, and efficacy of using LA for f-URS in treating stones, as an initial experience in the diagnosis related group (DRG) era of China.

METHODS

Patients who met the inclusion and exclusion criteria and were continuously included in the study Between 2021 and 2023. We analyzed the stone free status, postoperative complication rate, hospitalization costs, and presented key points of the procedure performed under LA that we had summarized over the past two years.

RESULTS

A study of 614 patients undergoing f-URS under LA for urinary stones in our hospital showed 83.4% stone-free rate with a mean operative time of 44.12 ± 16.63 minutes; 18 patients experienced fever postoperatively, and 12 had ureteral injuries. No severe complication was reported. The cost of LA was found to be only 1.7% of the DRG payment, which is around $40. The highest VAS scores were observed during the sheath insertion, with STAI scores decreasing during and after surgery.

CONCLUSIONS

The study revealed that f-URS administered under LA was a well-tolerated, efficient, safe, and economical procedure. In the DRG era, this new anesthetic option for f-URS provides urologists with a more cost-effective alternative.

Comparison of diagnosis-related group based reimbursement and case-mix index within hospitalized patients before and after modified malnutrition diagnosis

BACKGROUND AND OBJECTIVES

Lack of professional and accurate diagnosis of malnutrition led to a reduction in Diagnosis Related Group (DRG) payment and a decrease in Case-Mix Index (CMI). The aim of this study was to explore the effects of adding a proper nutritional diagnosis and modifying complication groups on DRG payment and CMI.

METHODS AND STUDY DESIGN

Retrospective analysis was performed on patients ad-mitted to the hospital from January to June 2022 who had received a nutritional assessment. Patients were diagnosed as well-nourished, mild malnutrition, moderate malnutrition or severe malnutrition according to patient-generated subjective global assessment (PG-SGA) scores within 24 hours of admission. CMI and DRG hospital internal control standards were recalculated and compared with the original values.

RESULTS

A total of 254 patients were enrolled, including 40 patients with mild malnutrition, 74 patients with moderate malnutrition and 122 patients with severe malnutrition. Of all subjects, 111 changed complication groups. The median of the DRG hospital internal control standard (12006.09 vs. 13797.19, p=0.01) and the median of CMI (0.91 vs. 1.04, p=0.026) were significantly higher than those before the diagnostic change. In patients with inflammatory bowel disease (IBD), the CMI value, hospital control standard of DRG, and the classification of DRG were significantly different from those before diagnosis revision (p<0.001).

CONCLUSIONS

Fully identification and correct coding of malnutrition cases are conducive for hospitals to receive appropriate DRG compensation, and further contribute to the improvement of medical quality and the economic sustain-ability of hospitals.

Impacts of Outpatient Payment Reforms on Volume and Expenditures in Public Hospitals: Evidence from a Quasi-Experimental Analysis in Zhejiang, China

Purpose

China developed an innovative episode-based payment scheme for outpatient care, namely "Ambulatory Patient Groups (APGs) + capitation" payment, to constrain inflation in outpatient expenditures. This study aimed to assess the effects of this payment method on volume and expenditures in Chinese public hospitals.

Methods

A quasi-experimental study was conducted with 7 municipal and 12 county hospitals from Jinhua as the intervention group and 15 municipal and 24 county hospitals from three neighbouring cities as the control group. The payment reform was introduced to municipal and county hospitals in the intervention group in January 2020 and January 2021, respectively. Monthly data on volumes and outpatient expenditures were collected from each hospital from January 2019 to December 2021. Controlled interrupted time-series analyses were performed to determine the effects of the funding reforms.

Results

Outpatient visits in municipal hospitals decreased by 1417.54 (p=0.048) per month on average compared with control ones after the reform was implemented, whilst that in county hospitals increased by 1058.04 (p=0.041) per month on average. The trend of drug expenditures (β 7=-1.41, p=0.019) in municipal hospitals dropped, which was accompanied by an immediate reduction in consumable expenditures (β 6 =-6.89, p=0.044). The funding reform also led to the significant declines in drug (β 6=-10.96, p=0.009) and consumable (β 6=-4.78, p=0.041) expenditures in county hospitals. Municipal hospitals experienced the drop in the trend of total outpatient expenditures (β 7=-3.99, p=0.018) over the same period.

Conclusion

The strength of the "AGPs + capitation" payment for outpatient care lies in its ability to control the excessive growth of medical expenses through correcting inappropriate incentives. However, minimising potential cost-shifting and risk-shifting to uninsured service items should be given attention.

Outcomes and Economic Evaluation in Delayed Two-Stage Breast Reconstruction in Romania: The Influence of Radiotherapy

The current paper is a retrospective cohort study conducted on sixty-seven patients who underwent two-stage breast reconstruction over a 5-year period (2015-2020). Forty-one (61.2%) patients received radiotherapy (RT group), and twenty-six (38.8%) did not (non-RT group). Data regarding patients, oncological therapies, type of reconstruction, time of hospitalization, complications, and costs were collected. The statistical analysis was performed using IBM SPSS Statistics 25. General complications were noted for 18 patients (43.9%) in the RT group and for 7 patients (26.9%) in the non-RT group. Major complications were observed only in the first group (five patients-12.2%). The mean time of hospitalization in the RT group was 14.83 days for patients with complications versus 9.83 days for those without complications and 15.5 days versus 8.63 days, respectively, in the non-RT group. The mean cost for patients without complications was 235.64 euros, whereas the cost for patients with complications was 330.24 euros (p = 0.001). Radiation therapy can affect the overall outcome by increasing the risk of complications and increasing costs; however, our paper shows that the association of alloplastic reconstruction in patients with radiotherapy can be performed safely and with low costs in carefully selected patients.

Challenges of implementing diagnostic-related groups and healthcare promotion in Iran: A strategic applied research

Background and Aim

Implementing the diagnostic-related groups (DRGs) promotes the efficiency of healthcare. Therefore, the present study aimed to identify the challenges facing implementing the DRGs in Iran.

Methods

The present study is a strategic applied research conducted in two phases. In the first phase, the challenges facing DRGs were extracted through a literature review. Then the collected data is entered into a checklist consisting of five sections including technological, cultural, organizational, strategic, and natural challenges. In the second phase, data were collected by purposive sampling and semistructured interviews with 10 managers of the Medical Services Organization of Tehran, Iran. Data analysis was performed by conventional content analysis using MAXQDA software and descriptive using SPSS software version 19.

Results

The challenges facing the implementing DGRs from the experts' perspective included technological, organizational, nature, strategic, and cultural in order of priority. The three main fundamental challenges were reported; lack of integrating the DGRs with health information system (70%), frequent changes of management (70%), reducing the quality of care following early patient discharge (60%).

Conclusion

The results of the present study showed that the DRG system faced with challenges and healthcare officials should apply policies and guidelines to reform the system before changing the reimbursement system in Iran. By considering the leading countries experiences in the nationalizing the DRG system field, the problems and solutions of the system can be identified and aid in the more successful implementation of these systems.

Patient characteristics and procedural variables are associated with length of stay and hospital cost among unilateral primary total hip arthroplasty patients: a single-center retrospective cohort study

BACKGROUND

Total hip arthroplasty (THA) is a successful treatment for many hip diseases. Length of stay (LOS) and hospital cost are crucial parameters to quantify the medical efficacy and quality of unilateral primary THA patients. Clinical variables associated with LOS and hospital costs haven't been investigated thoroughly.

METHODS

The present study retrospectively explored the contributors of LOS and hospital costs among a total of 452 unilateral primary THA patients from January 2019 to January 2020. All patients received conventional in-house rehabilitation services within our institute prior to discharge. Outcome parameters included LOS and hospital cost while clinical variables included patient characteristics and procedural variables. Multivariable linear regression analysis was performed to assess the association between outcome parameters and clinical variables by controlling confounding factors. Moreover, we analyzed patients in two groups according to their diagnosis with femur neck fracture (FNF) (confine THA) or non-FNF (elective THA) separately.

RESULTS

Among all 452 eligible participants (266 females and 186 males; age 57.05 ± 15.99 year-old), 145 (32.08%) patients diagnosed with FNF and 307 (67.92%) diagnosed with non-FNF were analyzed separately. Multivariable linear regression analysis revealed that clinical variables including surgery duration, transfusion, and comorbidity (stroke) among the elective THA patients while the approach and comorbidities (stoke, diabetes mellitus, coronary heart disease) among the confine THA patients were associated with a prolonged LOS (P < 0.05). Variables including the American Society of Anesthesiologists classification (ASA), duration, blood loss, and transfusion among the elective THA while the approach, duration, blood loss, transfusion, catheter, and comorbidities (stoke and coronary heart disease) among the confine THA were associated with higher hospital cost (P < 0.05). The results revealed that variables were associated with LOS and hospital cost at different degrees among both elective and confine THA.

CONCLUSIONS

Specific clinical variables of the patient characteristics and procedural variables are associated the LOS and hospital cost, which may be different between the elective and confine THA patients. The findings may indicate that evaluation and identification of detailed perioperative factors are beneficial in managing perioperative preparation, adjusting patients' anticipation, decreasing LOS, and reducing hospital cost.

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.

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.

Can case-based payment contain healthcare costs? - A curious case from China

We adopted a difference-in-difference (DID) design to evaluate the impact of a case-based payment pilot in Tianjin, China on hospital admission, utilization of varied therapeutic regimes, and the associated costs. We used claim data of all admissions of angina and acute myocardial infarction during July 2015 to June 2018, 18 months before and after the program. Our analyses were supported by convincing common trends tests and a couple of sensitivity analyses. As intended, for patients who received percutaneous coronary stenting (PCS) and were counted in the case-based payment system, we showed that the program decreased length-of-stay, per-admission spending, and out-of-pocket spending by 20.8%, 14.2%, and 95.5%, respectively, but did not increase readmissions. However, when considering all patients who suffered from the two types of coronary heart diseases, we found that the program otherwise increased per-admission spending by nearly 11%. As a result, the program took a perverse effect in increasing monthly spending for the health insurance scheme and the society by 1005.6 thousand USD (47·5%) and 1095·7 thousand USD (34·7%), respectively. Increases in hospital admissions, and proportion of performing PCS accounted for 66·7% and 39·2% of the rise, respectively. In addition, our analysis provided evidence of health providers' cream-skimming behaviors, including selecting younger patients with lower CCI in the case-based system, up-coding complications, and keeping higher cost patients in the fee-for-service payment system. We draw lessons that case-based payment may make an unintended impact that increases healthcare costs when incentives are not properly designed.

Impacts of a New Episode-Based Payment Scheme on Volume, Expenditures, and Efficiency in Public Hospitals: A Quasi-Experimental Interrupted Time-Series Study in Jinhua, China

Purpose

Based on the diagnosis-related groups payment, China developed an innovative episode-based payment scheme, called "payment method by disease types with point counting", to control health expenditures inflation. This study aimed to investigate the impacts of this new payment method on volume, expenditures, and efficiency in Chinese public hospitals.

Methods

The study sample consisted of 7 tertiary hospitals and 14 secondary hospitals in Jinhua (intervention group) and 4 tertiary hospitals and 14 secondary hospitals in Taizhou (control group). Monthly data points were collected for each sampled hospital from June 2016 to June 2019 using a self-administered questionnaire with impact evaluation indicators. Controlled interrupted time-series analysis was employed to estimate the effect of the new payment method.

Results

The significant slowing trends in inpatient expenditures per visit (tertiary hospitals: β₇=-123.16, p=0.042; secondary hospitals: β₇=-89.24, p=0.021) and out-of-pocket payments (tertiary hospitals: β₇=-4.18, p=0.027; secondary hospitals: β₇=-4.87, p=0.019) were observed after policy intervention. However, outpatient expenditures per visit in tertiary (β₇=1.67, p=0.018) and secondary hospitals (β₇=1.24, p=0.003) rose faster with the new payment method. Additionally, payment reform also caused an increase in the number of inpatient visits (β₇=100.01, p=0.038) and reduced the length of stay (β₇=-0.10, p=0.036) in tertiary hospitals.

Conclusion

The introduction of payment method by disease types with point counting causes the cost containment for inpatient care, whereas the increase in outpatient expenditures. The findings suggest this new payment scheme has the potential for rollout in other areas, but the cost-shifting from the inpatient to outpatient setting should be prevented.

Demystifying the role of anaesthetists in clinical coding in the Australian healthcare system

Despite the self-evident importance of hospital funding, many anaesthetists remain unsure of exactly how their daily work relates to hospital reimbursement. A lack of awareness of the nuances of the Australian hospital activity-based funding system has the potential to affect anaesthetic department reimbursement and thus resourcing. Activity-based funding relies on clinical coders reviewing clinical documentation and quantifying the care given to a patient during an admission. Errors in funding allocation may arise when there is a disconnect between the work performed and the information coded. In anaesthesia, there are several factors impeding this process, including clinical understanding of coding, system setup and coders' understanding of anaesthesia. This article explores these factors from the clinical anaesthetist's point of view and suggests solutions, such as awareness and education, clinician-coder cooperation and redesign of documentation systems at a systems level that anaesthetic departments can incorporate.

Feasibility and advantages analyses of wedge resection without mesentery detached approach applied to closure of loop ileostomy

OBJECTIVES

To evaluate the feasibility and advantages of wedge resection plus transverse suture without mesentery detached approach applied to loop ileostomy closure by analyzing the surgical data and the incidence of postoperative complications of patients undergoing this procedure.

METHODS

We performed a retrospective analysis of the hospitalization data of patients who underwent ileostomy closure surgery and met the research standards from January 2017 to April 2021 in Guangxi Medical University Cancer Hospital; all surgeries were performed by the same surgeon. The perioperative data were statistically analyzed by grouping.

RESULTS

In total, 65 patients were enrolled in this study, with 12 in the wedge resection group, 35 in the stapler group, and 18 in the hand suture group. There was no significant difference in operation time between the wedge resection group and stapler group (P > 0.05), but both groups had shorter operation time than that in the hand suture group (P < 0.05). The postoperative exhaustion time of wedge resection group was earlier than that of the others, and cost of surgical consumables in the wedge resection group was significantly lower than that in the stapler group, all with statistically significant differences (P < 0.05). By contrast, there were no statistically significant differences in postoperative complication incidences among the three groups.

CONCLUSIONS

The wedge resection plus transverse suture without mesentery detached approach is safe and easy for closure of loop ileostomy in selected patients, and the intestinal motility recovers rapidly postoperatively. It costs less surgical consumables, and is particularly suitable for the currently implemented Diagnosis-Related Groups payment method.

The Comparison of Various Types of Health Insurance in the Healthcare Utilization, Costs and Catastrophic Health Expenditures among Middle-Aged and Older Chinese Adults

Rapid aging in China is increasing the number of older people who tend to require health services for their poor perceived health. Drawing on the China Health and Retirement Longitudinal Study (CHARLS) 2018 data, we used two-part model and binary logistic regression to compare various types of health insurance in the healthcare utilization, costs and catastrophic health expenditures (CHE) among the middle-aged and older adults in China. Compared with uninsured, all types of health insurance promoted hospital utilization rate (ranged from 8.6% to 12.2%) and reduced out-of-pocket (OOP) costs (ranged from 64.9% to 123.6%), but had no significant association with total costs. In contrast, the association of health insurance and outpatient care was less significant. When Urban Employee Medical Insurance (UEMI) as reference, other types of insurance did not show a significant difference. Health insurance could not reduce the risk of CHE. The equity in healthcare utilization improved and healthcare costs had been effectively controlled among the elderly, but health insurance did not protect against CHE risks. Policy efforts should further focus on optimizing healthcare resource allocation and inclining toward the lower socio-economic and poor-health groups.

Effects of Endoscopic Submucosal Excavation With Non-Submucosal Injection on Stromal Tumors in Stomach

Background and Aim

Endoscopic submucosal excavation (ESE) is commonly used to treat gastrointestinal stromal tumors (GISTs), especially for tumor sizes within 2 cm; compared with the conventical ESE, the efficacy and safety of the no-submucosal injection (NSI) ESE remains unclear. The aim of this study was to assess the clinical efficacy and safety of NSI-ESE for gastric stromal tumors.

Methods

ESE was performed in 102 patients at our hospital between January 2018 and January 2020, and the clinical features, surgical outcomes, complications, cost of performance, pathological diagnosis, and risk classification were evaluated.

Results

All tumors were completely resected by endoscopic resection (ER), with a complete resection rate of 100%. It was achieved by ESE/EFTR (endoscopic full-thickness resection) in 49 cases with submucosal injection, and by ESE/EFTR in 53 cases with NSI-ESE. The mean surgical time in cases with submucosal injection was 25.86 ± 4.45 min, compared to the cases without submucosal injection (17.23 ± 3.47 min), and the difference was significant (p < 0.001); the exposure time of tumor, the time of complete excavation of tumor, procedure cost, and hospital stay in the NSI-ESE group were all lower than those cases with submucosal injection (p < 0.05). In the risk classification, 95 (93.1%) cases had a very low risk, 4 (4.0%) cases had a low risk, and 2 (2.0%) cases had a high risk. No recurrence or metastasis was observed during the follow-up period of 18 ± 6 months (range: 13–25 months).

Conclusions

NSI-ESE is a feasible, effective, and safe treatment for gastric GISTs; compared to the conventional ESE, NSI-ESE has the following advantages: it decreases procedure time, it lowers the risk of perforation, and it is cost-effective.

Cost Control of Treatment for Cerebrovascular Patients Using a Machine Learning Model in Western China

Background

Cerebrovascular disease has been the leading cause of death in China since 2017, and the control of medical expenses for these diseases is an urgent issue. Diagnosis-related groups (DRG) are increasingly being used to decrease the costs of healthcare worldwide. However, the classification variables and rules used vary from region to region. Of these variables, the question of whether the length of stay (LOS) should be used as a grouping variable is controversial.

Aim

To identify the factors influencing inpatient medical expenditure in cerebrovascular disease patients. The performance of two sets of classification rules, and the effects of the extent of control of unreasonable medical treatment, were compared, to investigate whether the classification variables should include LOS.

Methods

Data from 45,575 inpatients from a Healthcare Security Administration of a city in western China were used. Kruskal–Wallis H tests were used for single-factor analysis, and multiple linear stepwise regression was used to determine the main factors. A chi-squared automatic interaction detector (CHAID) algorithm was built as a decision tree model for grouping related data. The intensity of oversupply of service was controlled step by step from 10% to 100%, and the performance was calculated for each group.

Results

The average hospitalization cost was 1,284 US dollars, and the total was 51.17 million US dollars. Of this, 43.42 million were paid by the government, and 7.75 million were paid by individuals. Factors including gender, age, type of insurance, level of hospital, LOS, surgery, therapeutic outcomes, main concomitant disease, and hypertension significantly influenced inpatient expenditure (P < 0.05). Incorporating LOS, the patients were divided into seven DRG groups, while without LOS, the patients were divided into eight DRG groups. More clinical variables were needed to achieve good results without LOS. Of the two rule sets, smaller coefficient of variation (CV) and a lower upper limit for patient costs were found in the group including LOS. Using this type of economic control, 3.35 million US dollars could be saved in one year.

DRG grouping by machine learning: from expert-oriented to data-based method

Background

Diagnosis-related groups (DRGs) are a payment system that could effectively solve the problem of excessive increases in healthcare costs which are applied as a principal measure in the healthcare reform in China. However, expert-oriented DRG grouping is a black box with the drawbacks of upcoding and high cost.

Methods

This study proposes a method of data-based grouping, designed and updated by machine learning algorithms, which could be trained by real cases, or even simulated cases. It inherits the decision-making rules from the expert-oriented grouping and improves performance by incorporating continuous updates at low cost. Five typical classification algorithms were assessed and some suggestions were made for algorithm choice. The kappa coefficients were reported to evaluate the performance of grouping.

Results

Based on tenfold cross-validation, experiments showed that data-based grouping had a similar classification performance to the expert-oriented grouping when choosing suitable algorithms. The groupings trained by simulated cases had less accuracy when they were tested by the real cases rather than simulated cases, but the kappa coefficients of the best model were still higher than 0.6. When the grouping was tested in a new DRGs system, the average kappa coefficients were significantly improved from 0.1534 to 0.6435 by the update; and with enough computation resources, the update process could be completed in a very short time.

Conclusions

As a new potential option, the data-based grouping meets the requirements of the DRGs system and has the advantages of high transparency and low cost in the design and update process.

Prediction of Obstetric Patient Flow and Horizontal Allocation of Medical Resources Based on Time Series Analysis

Objective: Given the ever-changing flow of obstetric patients in the hospital, how the government and hospital management plan and allocate medical resources has become an important problem that needs to be urgently solved. In this study a prediction method for calculating the monthly and daily flow of patients based on time series is proposed to provide decision support for government and hospital management.

Methods: The historical patient flow data from the Department of Obstetrics and Gynecology of the First Hospital of Jilin University, China, from January 1, 2018, to February 29, 2020, were used as the training set. Seven models such as XGBoost, SVM, RF, and NNAR were used to predict the daily patient flow in the next 14 days. The HoltWinters model is then used to predict the monthly flow of patients over the next year.

Results: The results of this analysis and prediction model showed that the obstetric inpatient flow was not a purely random process, and that patient flow was not only accompanied by the random patient flow but also showed a trend change and seasonal change rule. ACF,PACF,Ljung_box, and residual histogram were then used to verify the accuracy of the prediction model, and the results show that the Holtwiners model was optimal. R2, MAPE, and other indicators were used to measure the accuracy of the 14 day prediction model, and the results showed that HoltWinters and STL prediction models achieved high accuracy.

Conclusion: In this paper, the time series model was used to analyze the trend and seasonal changes of obstetric patient flow and predict the patient flow in the next 14 days and 12 months. On this basis, combined with the trend and seasonal changes of obstetric patient flow, a more reasonable and fair horizontal allocation scheme of medical resources is proposed, combined with the prediction of patient flow.

Did paying drugs misuse treatment providers for outcomes lead to unintended consequences for hospital admissions? Difference-in-differences analysis of a pay-for-performance scheme in England

AIMS

To estimate how a scheme to pay substance misuse treatment service providers according to treatment outcomes affected hospital admissions.

DESIGN

A controlled, quasi-experimental (difference-in-differences) observational study using negative binomial regression.

SETTING

Hospitals in all 149 organisational areas in England for the period 2009-2010 to 2015-2016.

PARTICIPANTS

572 545 patients admitted to hospital with a diagnosis indicating drug misuse, defined based on International Classification of Diseases 10th Revision (ICD-10) diagnosis codes (37 964 patients in 8 intervention areas and 534 581 in 141 comparison areas).

INTERVENTION AND COMPARATORS

Linkage of provider payments to recovery outcome indicators in 8 intervention organisational areas compared with all 141 comparison organisational areas in England. Outcome indicators included: abstinence from presenting substance, abstinent completion of treatment and non-re-presentation to treatment in the 12 months following completion.

MEASUREMENTS

Annual counts of hospital admissions, emergency admissions and admissions including a diagnosis indicating drugs misuse. Covariates included age, sex, ethnic origin and deprivation.

FINDINGS

For 37 245 patients in the intervention areas, annual emergency admissions were 1.073 times higher during the operation of the scheme compared with non-intervention areas (95% CI = 1.049; 1.097). There were an estimated additional 3 352 emergency admissions in intervention areas during the scheme. These findings were robust to a range of secondary analyses.

CONCLUSION

A programme in England from 2012 to 2014 to pay substance misuse treatment service providers according to treatment outcomes appeared to increase emergency hospital admissions.

Urban-rural differences in healthcare utilization among beneficiaries in China's new cooperative medical scheme

BACKGROUND

The New Cooperative Medical Scheme (NCMS) is a voluntary social health insurance program launched in 2002 for rural Chinese residents where 80% of people were without health insurance of any kind. Over time, several concerns about this program have been raised related to healthcare utilization disparities for NCMS participants in urban versus rural regions. Our study uses 2015 national survey data to evaluate the extent of these urban and rural disparities among NCMS beneficiaries.

METHODS

Data for our study are based on the Chinese Health and Retirement Longitudinal Study (CHARLS) for 2015. Our 12,190-patient sample are urban and rural patients insured by NCMS. We use logistic regression analyses to compare the extent of disparities for urban and rural residence of NCMS beneficiaries in (1) whether individuals received any inpatient or outpatient care during 2015 and (2) for those individuals that did receive care, the extent of the variation in the number of inpatient and outpatient visits among each group.

RESULTS

Our regression results reveal that for urban and rural NCMS patients in 2015, there were no significant differences in inpatient or outpatient utilization for either of the dependent variables - 1) whether or not the patient had a visit during the last year, or 2) for those that had a visit, the number of visits they had. Patient characteristics: age, sex, employment, health status, chronic conditions, and per capita annual expenditures - all had significant impacts on whether or not there was an inpatient or outpatient visit but less influence on the number of inpatient or outpatient visits.

CONCLUSIONS

For both access to inpatient and outpatient facilities and the level of utilization of these facilities, our results reveal that both urban and rural NCMS patients have similar levels of resource utilization. These results from 2015 indicate that utilization angst about urban and rural disparities in NCMS patients do not appear to be a significant concern.

The impact of diagnosis related group payment on the performance of public hospitals

OBJECTIVE

To investigate the practical value of diagnosis related groups (DRGs) according to payment for assessing the performance of public hospitals.

METHODS

According to a random number table, 2400 patients were chosen from 3928 inpatients admitted for treatment in our hospital. Based on nodes implemented in the DRGs, these patients were assigned to the control group and the experimental group (1200 patients in each group). In the control group, patients didn't receive assistance with DRG payment (a clinical performance management approach was carried out based on the type of disease and cost), while patients in the experimental group received DRG. Bed turnover rate, hospitalization time, average cost, mortality, and subjective satisfaction were obtained and compared between the two groups.

RESULTS

Compared with the control group, bed turnover rate, hospitalization time, average cost, and mortality in the experimental group were all significantly decreased (P<0.05), while subjective satisfaction was increased (P<0.05).

CONCLUSION

DRG payment is beneficial for reduced clinical hospitalization time, cost, and mortality, and improved bed utilization rate and subjective satisfaction, which is worthy of clinical promotion.

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.