本研究利用CART 決策樹發掘Tw - DRGs 第三版(2005年12月版)DRG12701 與論量計酬支付之收益差之預測變數，並進一步了解醫院病人臨床特性。旨在探討Tw - DRGS 之DRG12701 個案心臟衰竭的臨床變異及對醫療機構之財務衝擊。研究個案為2004 年健保研究資料庫住院申報檔中DRG12701 個案共19,253 筆。變異數分析以SPSS12.0套裝軟體進行，醫院收益差之影響因素分析是採用Clememtine7 . 2 CART 決策樹軟體。結果顯示提供DRG12701 有執行呼吸治療／血液透析之主要醫療機構為區域醫院和醫學中心；住院日和呼吸治療／血液透析為收益差變異的重要預測變數。無論Tw - DRGs 第三版任何方案，對醫學中心、區域醫院及公立地區教學醫院都有負面財務衝擊，尤以公立醫學中心財務衝擊最大。公立醫學中心在平均每住院人次負收益差最大的決策樹規則集所佔個案數百分比，比其他權屬醫學中心、各權屬區域及公立地區教學醫院高。公立地區教學醫院在住院日大於(含)16 天且無呼吸治療／血液透析之決策樹規則集所佔個案數百分比高於其他權屬層級醫院，但公立醫學中心除外。本研究得到Tw - DRGS 第三版實施時，不同權屬層級醫院之財務衝擊差異，是因醫院之病人嚴重度不同所致。因此建議Tw -DRGs 應有機制反應疾病嚴重度，方能達成公平之支付制度。 The objective of this study sought to explore whether the Tw-DRG127O1 accurately reflect the clinical variation of heart failure and the impacts of Tw-DRGs 3rd (December 2005 version). Data on DRG 12701 discharges were acquired from 2004 NHIR data warehouse. SPSS 12.0 software was used for variance analysis and CART decision tree was performed with Clementine 7.2 version. The results revealed that the major providers for DRG 12701 patients performed with respiratory therapy/hemodialysis (RTHD) were regional hospitals and medical centers. Medical center, regional, and public district teaching hospitals for treating DRG 12701 patients had difficulty in obtaining appropriate reimbursement despite negotiation protocols. Of hospitals mentioned above, public medical center had the greatest negative “difference in revenue”. CART decision tree showed the determinants of “difference in revenue” were LOS and RTHD. Public medical center was with the largest percent patients in the tree set which had the greatest negative average “difference in revenue” per admission. The percent of patients of the longer stay (LOS ≧ 16 days) without RTHD tree sets was higher at public district teaching hospitals than other hospitals except medical centers. We conclude therefore that while changing to the Tw-DRGs payment system, the lack of taking into account of the severity of illness will be associated with negative financial impacts of hospital. Measures of severity of illness need to be incorporated for Tw-DRGs payment system to ensure equitable funding to hospitals.
