Association of the Swiss Diagnosis-Related Group Reimbursement System With Length of Stay, Mortality, and Readmission Rates in Hospitalized Adult Patients
Association of the Swiss Diagnosis-Related Group Reimbursement System With Length of Stay, Mortality, and Readmission Rates in Hospitalized Adult Patients
复制标题
DOI：
10.1001/jamanetworkopen.2018.8332
复制
发表时间：
2019-02-01
影响因子：
13.8
通讯作者：
Mueller, Beat
中科院分区：
文献类型：
--
作者：
Kutz, Alexander;Gut, Lara;Mueller, Beat
重要性 2012 年，瑞士的医院报销从按日付费服务制度转变为诊断相关团体 (SwissDRG) 制度。报销的这种变化是否会对护理质量和患者结果产生有害影响仍不清楚。 目的 研究 SwissDRG 实施与成人住院总人口的住院时间 (LOS)、院内死亡率和 30 天再入院率之间的关系，并按 5 个单独的诊断进行分层。 设计、设置和参与者 这项队列研究使用瑞士联邦统计局的管理数据来调查瑞士自 1 月份以来的医疗住院情况2009年1月1日至2015年12月31日。主要分析中包括所有成人内科住院患者的住院情况。具有 5 种常见医学诊断中的一种的患者被纳入子分析：社区获得性肺炎、慢性阻塞性肺病恶化、急性心肌梗死、急性心力衰竭和肺栓塞。采用间断时间序列模型来确定2012年实施SwissDRG后风险调整后的LOS、院内死亡率和30天再入院的时间趋势变化。分析时间为2018年3月1日至2018年6月30日以及2018年11月1日至2018年12月18日。主要结果和措施 每月患者层面的 LOS、院内死亡率和 30 天再入院率数据。 结果 样本总共包括 2 426 722 名住院成年患者。其中，1 018 404 名患者（41.9%；531 226 [52.2%] 为男性，中位[四分位距 (IQR)] 年龄为 69 [55-80] 岁）组成了 SwissDRG 之前的时期； 1 408 318 名患者（58.0%；730 228 [51.9%] 男性，中位 [IQR] 年龄为 70 [56-81] 岁）组成了 SwissDRG 后时期。总体 LOS 从 2009 年未经调整的平均 (SD) 8.0 (12.7) 天逐渐下降到 2015 年的 7.2 (17.3) 天。然而，随着 2012 年 SwissDRG 的实施，LOS 的减少并没有大幅增加（风险调整斜率，-0.0166 天；95% CI，-0.0223 至 -0.0110 天），调整斜率差异为 0.0000 天（95% CI，-0.0072 至 0.0072 天）。风险调整后的全因住院死亡率从 2009 年的 4.9% 下降到 2015 年的 4.6%，实施 SwissDRG 后下降幅度更大（实施前后月度斜率之差，-0.0115%；95% CI，-0.0190% 至 -0.0039%）。同期，风险调整后的 30 天再入院率从 2009 年的 14.4% 上升至 2015 年的 15.0%，实施 SwissDRG 后增幅更大（月斜率变化，0.0339%；95% CI，0.0254%-0.0423%）。研究发现，实施 SwissDRG 后，急性心肌梗死患者的 30 天再入院率大幅增加（调整后的斜率差异，0.1144%；95% CI，0.0617%-0.1671%）。结论和相关性 在瑞士的住院治疗中，SwissDRG 的实施似乎与再入院率的增加和院内死亡率的下降相关，但与逐渐降低的再入院率无关。历史控制期间观察到的 LOS 减少。
IMPORTANCE In 2012, hospital reimbursement in Switzerland changed from a fee-for-service per diem system to a diagnosis-related group (SwissDRG) system. Whether this change in reimbursement is associated with harmful implications for quality of care and patient outcomes remains unclear.OBJECTIVE To examine the association of the SwissDRG implementation with length of hospital stay (LOS), in-hospital mortality, and 30-day readmission rates in the overall adult inpatient population and stratified by 5 individual diagnoses.DESIGN, SETTING, AND PARTICIPANTS This cohort study used administrative data from the Swiss Federal Statistical Office to investigate medical hospitalizations in Switzerland from January 1, 2009, through December 31, 2015. All hospitalizations for adult medical inpatients were included in the main analysis. Patients who presented with 1 of the 5 common medical diagnoses were included in the subanalyses: community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, acute myocardial infarction, acute heart failure, and pulmonary embolism. An interrupted time series model was used to determine changes in time trends for risk-adjusted LOS, in-hospital mortality, and 30-day readmission after the implementation of SwissDRG in 2012. Analyses were performed from March 1, 2018, to June 30, 2018, and from November 1, 2018, to December 18, 2018.MAIN OUTCOMES AND MEASURES Monthly patient-level data for LOS, in-hospital mortality, and 30-day readmission rates.RESULTS The sample included a total of 2 426 722 hospitalized adult patients. Of this total, 1 018 404 patients (41.9%; 531 226 [52.2%] male, median [interquartile range (IQR)] age of 69 [55-80] years) composed the before-SwissDRG period; 1 408 318 patients (58.0%; 730 228 [51.9%] male, median [IQR] age of 70 [56-81] years) composed the after-SwissDRG period. The overall LOS gradually decreased from unadjusted mean (SD) 8.0 (12.7) days in 2009 to 7.2 (17.3) days in 2015. This reduction in LOS, however, was not substantially greater with the implementation of SwissDRG in 2012 (risk-adjusted slope, -0.0166 days; 95% CI, -0.0223 to -0.0110 days), with an adjusted difference in slopes of 0.0000 days (95% CI, -0.0072 to 0.0072 days). Risk-adjusted all-cause in-hospital mortality declined from 4.9% in 2009 to 4.6% in 2015, with a substantially greater decline after implementation of SwissDRG (difference between monthly slopes before and after implementation, -0.0115%; 95% CI, -0.0190% to -0.0039%). In the same period, risk-adjusted 30-day readmission rates increased from 14.4% in 2009 to 15.0% in 2015, with a greater increase after SwissDRG implementation (change in monthly slope, 0.0339%; 95% CI, 0.0254%-0.0423%). Patients with acute myocardial infarction were found to have a substantially greater increase after SwissDRG implementation in 30-day readmission rates ( adjusted difference in slopes, 0.1144%; 95% CI, 0.0617%-0.1671%).CONCLUSIONS AND RELEVANCE Among medical hospitalizations in Switzerland, SwissDRG implementation appeared to be associated with an increase in readmission rates and a decrease in in-hospital mortality but not with the gradual decrease in LOS observed in the historical control period.