背景: 中央健康保險局於2010年1月實施全民健康保險住院診斷關聯群(Taiwan Diagnosis Related Groups,Tw-DRGs),目的為提昇醫療服務效率和改善病人照護品質與療效。過去其他國家實施診斷關聯群的經驗,實施後醫院以成本為導向,為減少醫療浪費,在照護病人過程中縮減住院日數或醫療耗材,可能導致病人出院時病情不穩定或提早出院,節省成本卻可能影響醫療品質。因此,診斷關聯群制度下的醫療照護品質是重要議題。 研究目的: 探討Tw-DRGs實施前後,以住院死亡率與出院後14天再住院率的變動情形,來呈現診斷關聯群對醫療品質的影響。 研究方法: 本研究採縱斷面次級資料分析與前後測研究設計,利用Tw-DRGs實施第一年第一階段導入的97項DRGs案件為研究對象,以醫院為分析單位,自變項為實施Tw-DRGs,依變項為醫療品質指標包含住院死亡率與出院後14天再住院率,14天再住院案件依據同一個人在相同MDC下14天內含跨院的案件,利用配對t檢定比較同一家醫院2009年實施Tw-DRGs前與2010年實施Tw-DRGs後醫療品質的改變情形;以Probit分析,控制醫院特性,比較實施Tw-DRGs前後對醫療品質的影響。資料來源為國家衛生研究院全民健康保險研究資料庫。 研究結果: 1.住院死亡率: Tw-DRGs實施前2009年死亡率為0.11%,實施後2010年死亡率為0.18%,實施後住院死亡率上升,配對t檢定p值為0.11不顯著;以Probit分析,控制醫院特性,實施Tw-DRGs後住院死亡率Probit值為0.094,p值為0.309不顯著。 2.出院後14天再住院率: Tw-DRGs實施前2009年再住院率為0.25%,實施後2010年再住院率為0.97%,實施後出院後14天再住院率上升,配對t檢定p值為0.025顯著;以Probit分析,控制醫院特性,實施Tw-DRGs後出院後14天再住院率Probit值為0.349,p值<0.001顯著。 結論:實施Tw-DRGs後住院死亡率變化不顯著;出院後14天再住院率上升且顯著,顯示實施Tw-DRGs後的醫療品質有下降情形。
Background: Since January 2010, the Bureau of National Health Insurance started the Taiwan Version of Diagnosis Related Groups (Taiwan Diagnosis Related Groups, Tw-DRGs), to improve the efficiency of medical services, the quality of patient care, and its efficacy. Previously implementation of DRGs in other countries, hospitals became more cost-oriented. To save medical costs, hospitals may decrease the average length of stay or reduce the use of medical supplies, and these strategies may cause early discharge, saving medical cost but affect medical care quality. Therefore, the quality of medical care is one of the most important issues under Tw-DRGs. Objective: To explore changes in hospital mortality and 14-day readmission rates before and after the implementation of Tw-DRGs to present the impacts on medical care quality. Methods: This study used longitudinal secondary data analysis and a before–after study design, analyzing 97 cases of DRGs in the first year of the first stage implementation of Tw-DRGs and hospitals as the unit of analysis. The independent variable is the implementation of Tw-DRGs and the dependent variables are indicators of medical quality, including hospital mortality and 14-day readmission rate. 14-day readmission rate referred to the same individuals under the same MDC, including cross-hospital ones within 14-days after discharge. This study compares the medical care quality of the same hospital before and after Tw-DRGs by paired t-test. Controlling hospital characteristics, assess changes in medical care quality before and after Tw-DRGs by Probit analysis. Secondary data comes from the National Health Insurance Research Database (NHI). Results: 1.Hospital mortality: The hospital mortality was 0.11% before Tw-DRGs in 2009, and 0.18% after Tw-DRGs in 2010. Hospital mortality increased after Tw-DRGs, but not significant p=0.11 by paired t-test. Controlling hospital characteristics, the result of Probit analysis after Tw-DRGs was 0.094, and the P=0.309 that not significant. 2.14-day readmission rate: The 14-day readmission rate was 0.25% before Tw-DRGs in 2009 and 0.97% after Tw-DRGs in 2010. The 14-day readmission rate increased significantly p=.025 by t-test after Tw-DRGs. Controlling hospital characteristics, the Probit analysis for the 14-day readmission rate was 0.349 and the p<0.001 after Tw-DRGs. Conclusion: There was significant increase in 14-day readmission rate and no significant change in hospital mortality after Tw-DRGs. However, indicating a decrease on the medical care quality after the implementation of Tw-DRGs.