S市按病种分值付费对公立医院绩效考核病种质量的影响

Impact of Diagnosis-Intervention Packet payment in S City on the healthcare quality of diseases concerned by the national public hospital performance assessment

目的:分析S市国家公立医院绩效考核关注病种在2019年7月实施按病种分值付费改革后医疗服务质量的变化情况。方法:收集2017年7月—2021年6月S市公立二、三级医院的职工保险参保患者住院病案首页数据,采用双重差分法比较改革前后首批DIP付费试点医院(干预组)和非DIP付费试点医院(对照组)的4个典型诊断和2个典型手术操作的住院天数、院内死亡率、30天内全因再入院率变化情况。结果:试点医院相比非试点医院,改革后国家公立医院绩效考核关注的典型诊断和手术操作的住院天数分别上升0.228天、下降0.568天,但均无统计学意义。典型诊断和典型手术操作的院内死亡率分别下降0.5个百分点(P=0.047)、1.1个百分点(P=0.000);30天内全因再入院率分别下降2.0个百分点(P=0.017)、4.9个百分点(P=0.014)。结论:S市按病种分值付费改革后国家公立医院绩效考核关注病种的住院天数变化方向不一致;院内死亡率和再入院率提示的服务质量改善。按病种付费改革中需密切监测多病种、多维度的服务质量变化。

Objective:To analyze the changes in the quality of healthcare for selected diseases following the implementation of the Diagnosis-Intervention Packet(DIP)payment reform in July 2019,which are covered by the National Public Hospital Performance Assessment(NPHPA)in S city.Methods:From July 2017 to June 2021,the homepage data of inpatient cases of employee insurance insured patients in public secondary and tertiary hospitals in S City were collected,and the difference-in-differences method was used to compare the changes in length of stay hospitalization,in-hospital mortality,and all-cause readmission rate within 30 days of four typical diagnoses and two typical procedures in the first DIP pilot hospitals(intervention group)and non-DIP pilot hospitals(control group)before and after the reform.Results:Compared with non-pilot hospitals,length of stay for typical diagnoses and procedures concerned by the NPHPA in pilot hospitals after the reform increased by 0.228 days and decreased 0.568 days respectively,but were not significant.For typical diagnosis and typical surgical procedures,in-hospital mortality rate declined by 0.5 percentage points(P=0.047),1.1 percentage points(P=0.000)respectively.All-cause readmission rate within 30 days decreased 2.0 percentage points(P=0.017),4.9 percentage points(P=0.014)respectively.Conclusions:The change direction of length of stay in diseases concerned by the NPHPA was inconsistent after the DIP payment reform in S city,while the quality of care reflected by the in-hospital mortality and readmission rate improced.It is necessary to closely monitor the changes in quality of multiple diseases and dimensions in the case-based payment reform.