肺结核患者住院费用影响因素与按疾病诊断相关分组方案研究

Research on the factors influencing tuberculosis hospitalization costs and diagnosis related grouping

目的:基于住院费用影响因素的研究,探索在结核病分类下肺结核的按疾病诊断相关分组(diagnosis related groups,DRG)方案,依据费用情况确定分组,为合理划分DRG分组提供依据。方法:收集首都医科大学附属北京胸科医院2018年1月1日至2020年12月31日确诊患者1812例。依据肺结核分类完成基本组层面的划分,肺结核DRG基本组划分为敏感肺结核和耐药肺结核2组,敏感肺结核组有109例,耐药肺结核有1703例。对不同要素下患者住院费用的中位数(四分位数)进行统计描述;采用Kruskal-Wallis H检验、Mann-Whitney U检验和多重线性回归方法对影响住院费用的因素进行分析,P<0.05为差异有统计学意义;采用决策树处理数据完成细分组的划分;采用变异系数(coefficient of variation,CV)和方差减少量(reduction in variance,RIV)对分组的组内同质性和组间异质性进行评价,采用Kruskal-Wallis H检验对分组结果进行检验。结果:分析不同要素下患者群体住院费用发现,年龄≤30岁的住院费用中位数(四分位数)为20586.66(13656.41,90163.58)元,年龄31~40岁的是23256.47(17490.26,82919.32)元,年龄41~50岁的是21154.19(13615.14,76240.28)元,年龄51~60岁的是23544.59(16325.46,87608.46)元,年龄61~70岁的是25190.27(20528.01,78321.02)元,年龄≥71岁的是24890.24(18424.86,91662.89)元;药物敏感的患者住院费用中位数(四分位数)是21693.82(16567.26,91662.89)元,耐多药患者是21866.32(14390.17,87896.56)元,单耐药患者是23703.70(18021.55,90163.58)元,广泛耐药患者是18846.98(11400.11,78321.02)元,多耐药患者是23900.67(16006.08,58834.03)元;无并发症的患者住院费用中位数(四分位数)是9730.37(5361.33,28053.18)元,并发症数量为1~5个的患者是20378.65(14110.72,90163.60)元,并发症数量为6~10个的是24072.81(17966.19,87608.46)元,并发症数量为11~15个的患者是24953.26(18411.59,87896.56)元,并发症数量为16~20个的是32530.70(23904.41,74195.40)元,并发症数量≥21个的患者住院费用中位数(四分位数)是29647.02(25707.11,91662.89)元;初治患者的住院费用中位数(四分位数)是23594.24(17890.74,91662.89)元,复治患者是21662.63(14369.58,87896.56)元。Kruskal-Wallis H检验显示,按照年龄、耐药类型和不同并发症分组后住院费用组间差异具有统计学意义(H值分别为58.510、19.556、92.424,P值均<0.05);Mann-Whitney U检验显示,按照初治/复治分组后住院费用组间差异具有统计学意义(U=-4.422,P<0.05)。是否有并发症、初治复治类型、住院时间、年龄均进入了回归模型。在细分组层面,肺结核DRG组划分了5组:药物敏感肺结核;耐药肺结核、住院时间≤7 d;耐药肺结核、住院时间8~14 d;耐药肺结核、住院时间15~20 d;耐药肺结核、住院时间≥21 d。药物敏感肺结核组住院费用中位数(四分位数)是21693.82(16567.26,91662.89)元,耐药肺结核、住院时间≤7 d组住院费用中位数(四分位数)是12334.88(7141.91,59741.83)元,耐药肺结核、住院时间8~14 d住院费用中位数(四分位数)是20842.28(16459.27,80496.43)元;耐药肺结核、住院时间15~20 d住院费用中位数(四分位数)是26612.13(21683.16,90163.58)元;耐药肺结核、住院时间≥21 d住院费用中位数(四分位数)是33326.87(25680.93,87896.56)元。Kruskal-Wallis H检验结果显示H值为660.241,P<0.05,各组间差异有统计学意义。各组CV值均<1,符合DRG分组标准;从依据敏感耐药类型划分的基本组到细分组层面,RIV值从0.01%上升至33.82%,差异性显著提升。结论:在分组要素中引入耐药类型、治疗类型的要素,利于将临床相似性和资源消耗的相似性紧密结合,提高分组的准确性和科学性,建议按照不同肺结核类型分组并在此基础上确定支付标准,提高DRG分组与支付的科学性。

Objective:Based on the research on the influencing factors of hospitalization costs,explore the scheme of diagnosis related groups(DRG)of tuberculosis under the classification of tuberculosis,determine the grouping according to the cost,and provide a basis for reasonable grouping of DRG.Methods:We collected 1812 confirmed patients from Beijing Chest Hospital affiliated to Capital Medical University from January 1,2018 to December 31,2020.According to the classification of pulmonary tuberculosis,the basic group level was divided into two groups:sensitive pulmonary tuberculosis and drug-resistant pulmonary tuberculosis.There were 109 cases in the sensitive pulmonary tuberculosis group and 1703 cases in the drug-resistant pulmonary tuberculosis group.Statistical description of the median and quartile of hospitalization expenses for patients under different factors was done.Kruskal Wallis H-test,Mann Whitney U-test,and multiple linear regression methods were used to analyze the factors affecting hospitalization expenses.P<0.05 indicates a statistically significant difference.Using decision trees to process data to complete the division of sub-groups.The coefficient of variation(CV)and reduction in variance(RIV)were used to evaluate intra group homogeneity and inter group heterogeneity between the groups,and the Kruskal Wallis H test was used to test the group results.Results:We analyzed the hospitalization expenses of patient groups under different factors.It was found that the median(quartile)hospitalization expenses for patients aged≤30 years old were 20586.66(13656.41,90163.58)yuan,23256.47(17490.26,82919.32)yuan for those aged 31-40 years old,21154.19(13615.14,76240.28)yuan for those aged 41-50 years old,23544.59(16325.46,87608.46)yuan for those aged 51-60 years old,25190.27(20528.01,78321.02)yuan for those aged 61-70 years old,and 24890.24(18424.86,91662.89)yuan for those aged≥71 years old.The median(quartile)hospitalization cost for drug sensitive patients was 21693.82(16567.26,91662.89)yuan,21866.32(14390.17,87896.56)yuan for multidrug-resistant patients,23703.70(18021.55,90163.58)yuan for monodrug-resistant patients,18846.98(11400.11,78321.02)yuan for extensively resistant patients,and 23900.67(16006.08,58834.03)yuan for multidrug-resistant patients.The median(quartile)hospitalization cost for patients with 0 complications was 9730.37(5361.33,28053.18)yuan,20378.65(14110.72,90163.60)yuan for patients with 1-5 complications,24072.81(17966.19,87608.46)yuan for patients with 6-10 complications,24953.26(18411.59,87896.56)yuan for patients with 11-15 complications,32530.70(23904.41,74195.40)yuan for patients with 16-20 complications,and 29647.02(25707.11,91662.89)yuan for patients with≥21 complications.The median(quartile)hospitalization cost for newly treated patients was 23594.24(17890.74,91662.89)yuan,while for re-treated patients it was 21662.63(14369.58,87896.56)yuan.Kruskal Wallis H-test showed that there was statistical significance in hospitalization expenses between groups after grouping according to age,drug-resistance type,and different complications(H-values were 58.510,19.556,and 92.424,respectively,P<0.05).The Mann Whitney U-test showed that there was a statistically significant difference in hospitalization expenses between groups after initial/recurrent treatment(U=-4.422,P<0.05).The presence of complications,type of initial and recurrent treatment,length of hospital stay,and age were all included in the regression model.At the sub-group level,the DRG group of pulmonary tuberculosis was divided into 5 groups:drug sensitive pulmonary tuberculosis,drug-resistant pulmonary tuberculosis with hospitalization time≤7 days,drug-resistant pulmonary tuberculosis with hospitalization time 8-14 days,drug-resistant pulmonary tuberculosis with hospitalization time 15-20 days,and drug-resistant pulmonary tuberculosis with hospitalization time≥21 days.The median(quartile)hospitalization cost for drug sensitive pulmonary tuberculosis group was 21693.82(16567.26,91662.89)yuan.While for drug-resistant pulmonary tuberculosis with hospitalization time≤7 days group,the median(quartile)hospitalization cost was 12334.88(7141.91,59741.83)yuan.For drug-resistant pulmonary tuberculosis with hospitalization time 8-14 days,the median(quartile)hospitalization cost was 20842.28(16459.27,80496.43)yuan.The median(quartile)hospitalization cost for drug-resistant pulmonary tuberculosis with hospitalization time 15-20 days was 26612.13(21683.16,90163.58)yuan.The median(quartile)hospitalization cost for drug-resistant pulmonary tuberculosis with hospitalization time≥21 days was 33326.87(25680.93,87896.56)yuan.The Kruskal Wallis H-test results showed an H-value of 660.241,with a P<0.05,indicating a statistically significant difference between the groups.The CV values of each group were less than 1,which met the DRG grouping criteria.From the basic group divided by sensitive drug-resistance type to the sub-group level,the RIV value increased from 0.01%to 33.82%,with a significant increase in differences.Conclusion:Introducing elements of drug-resistance type and treatment type into grouping elements was conducive to closely combining clinical similarity and resource consumption similarity,improving the accuracy and scientificity of grouping.It is recommended to group according to different types of pulmonary tuberculosis and determine payment standards based on this to improve the scientificity of DRG grouping and payment.