医学ppt课件drgprinciples and structure drg原则和结构

1 DRG-principles and structure DRG原则和结构 Changchun, May 2011 长春，2011年五月 Dr. Jiri Nemec- key expert, health management 吉利核心专家，健康管理 日程Agenda nCase-mix classification systems in general 病例混合分类系统 nHistory of DRG DRG的发展历史 nPrinciples of DRG 原理 nDesign of DRG 设计 nApplications of DRG应用 Case-mix classification systems in general 病例混合分类系统 3 医疗服务的分类系统Classification systems for health care n长期的使用的历史-如疾病的国际分类法 long history of usage-e. g. International Classification of Diseases n将对象或现象按照具体的属性分配到几个组（ 可能是重叠的） allocation of a set of objects or phenomena to several (possible overlapping) groups based on specific attributes of the objects or the phenomena 4 什么是病例-混合分类系统What are case -mix classification systems 他们They n是一种提供高质量医疗服务信息的科学方法represent a scientific approach to delivery of quality information on health care, n侧重于建立每个治疗病例的科学分类以及利用此信息 进行医疗服务的管理 focus on creation of useful classification of episodes of treatment and on utilization of this information for managing of health care provision 混合案例的分类系统Case-mix classification systems 病例的属性 attributes of a case 成本及临床的相似性 Cost & clinical similarity 相对权重 relative weight 病例cases 病例混合分类系统的应用Utilization of case-mix classification systems n可以对服务的数量、服务的复杂性两个方面测量（考 核） suitable measure of volume and complexity of delivered health care n对监控医疗服务质量进行风险校正 risk adjustment for monitoring of quality of health care History of DRG (Diagnosis Related Groups) DRG的发展历史 8 病例混合分类系统的按病种付费Case- mix classification system DRG-history n急性病住院的病例分类 classification of cases of acute in-patient care n起源于美国，用于监测医院服务的利用和相关的费用（耶鲁大学， 上一世纪的六十年代） originated in the US (Yale university, sixties of the last century) as a tool for monitoring of utilization of services in hospitals and of its associated costs n新泽西州首次把它作为预付制the first major application as a prospective payment system (PPS) in the state New Jersey (US) n从1983年开始，作为预付方法在美国Medicare中使用 using as PPS for all patients in the program Medicare (US) since 1983 病例混合分类系统的按病种付费Case- mix classification system DRG-history n在美国以及欧盟的应用为了used in the US and Europe for: q用于对住院治疗的支付费用remuneration of in-patient care q监控医疗服务的质量以及和绩效monitoring of performance and quality of health care q对医院的管理management of hospitals Principles of DRG DRG的原理 11 按诊断分组的指导原则Guiding principles of DRG n便于管理的分组数量（数百） manageable number of groups (several hundreds) n每种病例被准确地分类到一个DRG组别中 each case classified to exactly one DRG group n划分到同一类小组的病例是临床上相似的相近的，同 时治疗费用的相近的 cases classified in the same group are clinically similar and represent similar costs of treatment 按诊断分组的病例特征变量Attributes of cases used for DRG classification n病人的年龄patients age n主要诊断以及二次诊断main diagnosis and secondary diagnosiss n是否进行了手术，如果有surgical procedure if any n出院的情形way of discharging n出生体重birth weight 主要诊断类别Major Diagnostic Categories n第一层次的分类1st level of splitting q分为约25个主要诊断类别（MDC） around 25 MDC q在一个主要诊断类别的病例都是关于一个器官或者身 体某一部位的病例all cases in one MDC relate to treatment of one organ or part of a body 主要诊断类别-例子Major Diagnostic Categories-examples nMDC 1 神经系统的疾病及缺陷MDC 1 Diseases and defects of nervous system nMDC 2 眼部的疾病及缺陷 MDC 2 Diseases and defects of eye nMDC 3 耳鼻喉疾病及缺陷MDC 3 Diseases and defects of ear, mouth, nose, throat nMDC 4 呼吸系统的疾病及缺陷MDC 4 Diseases and defects of respiratory system nMDC 5 循环系统的疾病及缺陷 MDC 5 Diseases and defects of circulatory system 按病种付费的基本组Base DRG groups n第二层面 q约300个按病种付费组around 300 base DRG groups q根据治疗或一些相关的主要诊断被分到上述的按诊断分类中 all cases in one base DRG relate to treatment of one or several related main diagnosis or q或则按几个相关的手术治疗分到诊断分类中or several related surgical procedures 诊断分组的基本组-例子Base DRG groups-examples nMDC 4 呼吸系统的疾病及缺陷MDC 4 Diseases and defects of respiratory system q 基于0438哮喘和支气管炎 Base 0438 Asthma and bronchiolitis n根据ICD-10诊断J45,J46,J41,J21, J98 diagnosis J45,J46,J41,J21, J98 according to ICD-10 q 基于0401的大胸部手术 Base 0401 Big chest procedures 按病种付费组DRG groups（按基本组 再细分） n第三层面 q近900个按诊断分组的组around 900 DRG groups q一个基本组按照第二诊断（次要诊断）（通常）被分为三组 a base group splits according to secondary diagnosis to (usually) three DRG groups q不包括并发症和其它疾病的发生without Complications and Comorbidity (CC) q包括并发症和其它疾病的发生with CC q包括主要的并发症和其它疾病的发生with major CC 按诊断分组-例子DRG groups-examples nMDC 4 呼吸系统的疾病和缺陷Diseases and defects of respiratory system q 0438 的哮喘病和支气管炎基本组 Base 0438 Asthma and bronchiolitis n根据ICD-10诊断J45,J46,J41,J21, J98 diagnosis J45,J46,J41,J21, J98 according to ICD-10 q 按诊断分组04381，不包括CC的哮喘病和支气管炎 DRG group 04381 Asthma and bronchiolitis without CC q按诊断分组04382，包括CC的哮喘病和支气管炎 DRG group 04382 Asthma and bronchiolitis with CC q按诊断分组04383，包括主要的CC哮喘病和支气管炎 DRG group 04383 Asthma and bronchiolitis with major CC 按诊断分组的决策图表Decision tree of the DRG MDC 1MDC 2MDC n 内科medical groups ne 主要的诊断 What main diagnosis? 手术流程Surgical procedure ? 主要的诊断 What main diagnosis? 重要的第二诊断 Important secondary diagnosiss? 手术组surgical groups 具体手术？What procedure? medical groups without CCmedical groups withCC 如何对医院的病例进行分类How to classify hospital cases ? n依靠一种叫做GROUPER的软件 by means of a software called GROUPER n输入：主要诊断（第一诊断），次要诊断（第二诊断），手术编 码，病人年龄，出院编码，出生体重 input: main diagnosis, secondary diagnosiss, code of surgical procedure, age of patient, code of discharge, birth weight n输出：合理的按病种付费分组代码 output: code of an appropriate DRG group Example of a grouper (IR DRG) DRG分组器（软件）（online model在线模式） Design of DRG DRG的设计 23 DRG与临床路径 DRG versus clinical pathways nDRG qClustering 病例的分类、分组 qclinical assessment by a panel of professionals 由 专业人员小组进行临床评估 qstatistical evaluation 统计分析评价 nclinical pathways 临床路径 q clinical assessment by a panel of professionals 由专业人员小组进行临床评估 24 Statistical measure of homogeneity 对同质性的统计测量指标 方差系数（变异系数） Coefficient of variance is mostly used (CV): SUM (yi -Ag)2 CV = 1 n-1 - - SUM yi - n =100%） distance of LOS between DRG groups belonging to one base group should be 2 days at least (or by 100 % more costly) n90%可信限没有重叠90 % confidence intervals should be disjunctive 28 分组的效果Effectiveness of grouping Observed indicator MDC 主要组 组 MDC and split surgical/medical 基本组+是否有手 术 Base groups 基础组 DRG Groups DRG组 Costs10.8 %19.9 %43.8 %53.1 % 29 1. 不同分组水平下的方差系数 Values of R2 w