診斷組合之臨床圖譜－以尿路結石(DRG323-324)病人為例

Patient Acuity Level of Diagnosis-Related Groups (DRGs): Example of Urolithiasis (DRG323-324)

古雪鈴(Shei-Ling Ku) ； 韓揆(Kue Han) ； 林志明(Chih-Ming Lin) ； 陳宗泰(Chung-Tai Chen) ； 盧瑞華(Ruey-Hwa Lu)

《輔仁醫學期刊》 4卷4期 (2006/12) Pp. 187-192

摘要

背景和目的：醫療機構、健保局、病人間有著非常複雜且微妙的給付關係，規劃理想、公平、合理、簡單的給付制度是學術界及醫療界的努力標的。本研究目的嘗試以建立個別醫院診斷組合(DRGs)之臨床圖譜的給付精神，作為建議健保局與醫療機構雙向溝通、協調機制的依據與手段。方法：以個案醫院本身之尿路結石臨床資料、病人統計、現行及歷史費用分析，經過DRGs的互補方式，訂出屬於自己個別醫院的平均；以各種疾病之不同臨床狀況案例分配及其住院日、住院費用差異，鋪出個案醫院DRGs(DRG323-324)的病人臨床圖譜，以做為醫院與健保個別洽定費用時，以此圖譜作為給付依據。結果：個案醫院自2002年1月1日至2005年10月31日止，DRG323的個案共有256人、其平均住院日為3.2天、平均住院費用為31,568元。實施體外震波碎石術的個案共有175人佔68.4%、其平均住院日為2.7天、平均住院費用為34,782元，實施內視鏡取石術的病人數共有40人佔15.6%、其平均住院日為3.2天、平均住院費用為28,926元，實施以其他觀察輔助治療的病人共有41人佔16.0%、其平均住院日為5.3天、平均住院費用為21,512元。DRG324的個案共有215人、其平均住院日為2.0天、平均住院費用為17,765元。實施內視鏡取石術的個案共有134人佔62.3%、其平均住院日為2.1天、平均住院費用為21,033元，實施以其他觀察輔助治療的個案共有81人佔37.7%、其平均住院日為1.8天、平均住院費用為7,050元。結論：以個案醫院尿路結石(DRG323-324)的病人臨床圖譜分析基礎為例，作為向健保局提出申請給付之依據，相信可防止醫療機構不按醫療保險的政策實施醫療服務，或者醫療保險機構不尊重醫療管理的自身規律干涉醫療服務的弊端，而得到公平而雙方滿意的給付標準。

關鍵字

診斷組合 ； 尿路結石 ； 病人臨床圖譜分析

並列摘要

Background and Purpose: A fair, reasonable, and simple balanced billing payment system is desired by providers, payers, and patients in the healthcare industry. In this study, we sought to establish the clinical case mix component for the diagnosis related groups (DRGs) in an individual hospital. Methods: We analyzed urolithiasis patients clinical information, and past and present cost data to establish baseline data for DRG323-324 Results: There were 256 patients from January 1, 2002 to December 31, 2005 The average length of stay (LOS) was 32 days with a mean in hospital expense of NT $31,568. In total, 175 patients (68.4%) received extracorporeal shock wave lithotripsy (ESWL) (with a mean LOS of 2.7 days and expense of NT $34,782); while 40 received endoscopic removal of the urolithiasis (with a mean LOS of 32 days and expense of NT$28,926); the other 41 (16%) were merely observed in the hospital (with a mean LOS of 2.0 days and expense of NT$17,765). For 215 patients who underwent the DRG clinical pathway, the mean LOS was 2.0 days, and the mean expense was NT$17,765. None of these patients received ESWL, while 134 (62.3%) received endoscopic removal (with a mean LOS of II days and expense of NT$21,033), and 81 (37.7%) were medically observed (with a mean LOS of 1.8 days and expense of NT$7050). Conclusions: We believe that DRGs can help improve balanced billing, and we provide evidence for this in this study.

並列關鍵字

diagnosis-related groups ； urinary stone ； patient acuity level