| 摘要: | 本研究目的主要是探討DRG127『心臟衰竭與休克』之12701及12702個案人口學、臨床特性之差異性及分析Tw-DRGs第三版支付方式中之三個方案對醫療機構之財務衝擊，並利用CART決策樹演算法依收益差發掘歸納規則，瞭解收益差之預測變數以及各權屬層級醫院之個案特性。所使用方法研究個案為2004年全民健康保險研究資料庫住院申報檔中DRG127個案(排除尚未出院之切帳申報案件)，DRG12701個案19,253筆；DRG12702個案5,431筆，共24,684筆，與醫事機構基本資料檔串檔，取得醫院層級別，權屬別變數。統計方法有描述性統計(Descriptive statistics)、chi-square test檢定、t-test檢定、對數線性模式(log-linear analysis)、二因子變異數分析(two-way ANOVA) 、二因子重複量變異數分析(two-way repeated ANOVA)等，且利用資料探勘CART決策樹分析影響醫院財務衝擊之因素。結果顯示DRG12701與DRG12702之平均診斷編碼個數、平均處置編碼個數及平均住院日均有顯著差異(P<0.0001)，呼吸治療或洗腎之處置有無與DRG12701或DRG12702有關聯(P<0.0001)，有呼吸治療或洗腎個案相對於無呼吸治療或洗腎個案有4.18倍勝算是歸戶於DRG12701，並且應用 CART決策樹分析在控制性別、年齡、診斷數、處置數等變數下，住院日與有無使用呼吸治療或洗腎會影響收益差變異的重要變數，亦發現住院日愈長及有使用呼吸治療或洗腎的個案對財務衝擊愈大。DRG12701與DRG12702有60%以上個案在區域層級以上醫院。DRG12701平均每住院人次收益差正值之醫院以方案一為適當方案。就DRG12702而言，醫學中心以方案二為適當方案，其他權屬別層級醫院則以方案一為較適當。Tw-DRGs第三版對醫學中心、區域醫院及地區教學醫院有負面財務衝擊尤以醫學中心影響最大。公立醫學中心在平均每住院人次負收益差值最大的規則集所佔案件數比，無論是DRG12701或DRG12702或方案都比其他醫學中心、各權屬區域及地區教學醫院高。雖不同層級醫院Tw-DRGs第三版有基本診療加成但仍彌補不了醫院的虧損。本研究建議在面對即將導入Tw-DRGs支付制度下，醫療院所臨床路徑之規劃、醫師主動參與、以及健保局針對疾病嚴重度分析需有完善準備，方能達成此支付制度實施之目標，亦即在於控制國內醫療費用成長之理想。
DRG 12701 heart failure and shock with CC was the leading diagnosis-related group discharge diagnosis of MDC 5 in 2004 Taiwan NHI research data. The objective of this study sought to define the demographic and clinical characteristic-related differences between DRG 12701 and 12702 (heart failure and shock without cc). It also explored the hospital financial risk associated with these patients under the Tw-DRGs 3rd version. CART decision tree was conducted to build up the model to investigate the important variables that can explain the variation of difference in revenue between Tw-DRGs payment system and fee-for-services. Characteristics of hospitalized patient were further identified. Materials and methods consisted of data on DRG 127 inpatient discharge acquired from 2004 NHI research data warehouse, undischarged claim data were excluded. This study reviewed the data with regards to demographic and hospital characteristics, length of stay (LOS), charges, the number of diagnoses and procedures, and ICD codes of mechanical ventilation and hemodialysis. The results were analyzed by the chi-square test, the t-test, log-linear analysis, two-way ANOVA, two-way repeated ANOVA that were performed with SPSS 12.0 version. CART decision tree were performed with Clementine 7.2 version. It was found out that the mean number of diagnoses, procedures and LOS of DRG 12701 was statistically different from DRG 12702 (p< 0.0001). The more patients with the procedure “mechanical ventilation and hemodialysis” were assigned into DRG12701 (odds ratio, 4.18, p<0.0001). After controlling for the other covariates, CART decision tree showed that the determinants of difference in revenue were LOS and the procedures “mechanical ventilation and hemodialysis.” More than 68 per cent of DRG 127 patients were cared at regional hospitals and medical centers. In terms of negotiation protocol of DRG 12701 for hospitals, protocol 1 was appropriate among three protocols if the mean of difference in revenue per admission of hospital was positive, otherwise protocol 2 was appropriate for hospitals. However, the appropriate protocol was determined by hospital accreditation as to DRG 12702, protocol 2 was appropriate for tertiary hospitals; protocol 1 was appropriate for district, district teaching, and regional hospitals. Although Tw-DRGs 3rd version had evolved to explain the quality of hospitals, this result demonstrated that tertiary, regional, and district teaching hospitals for treating DRG 127 patients had difficulty in obtaining appropriate reimbursement. We conclude therefore that while changing to the Tw-DRGs system, the lack of taking into account of the severity of heart failure was associated with negative financial impact of hospitals. Of all the different hospital levels, public medical centers have the highest negative difference in revenue. Measures of severity of illness need to be reviewed and incorporated for Tw-DRGs refinement to ensure equitable funding to tertiary, regional, and district teaching hospitals. |
