某三甲医院泌尿外科QY组数据分析

Data analysis of QY Group in urology department of a three A and tertiary hospital

目的 通过分析某三甲医院泌尿外科疾病诊断相关分组(DRG)进入歧义(QY)组病例原因,合理减少QY组,提高DRG入组准确率。方法 调取某市DRG分组数据中某院泌尿外科2022年4月1日—11月30日DRG实际付费医保结算清单,提取QY组相关信息。从某院联众数字化病案浏览器中调取QY组病例的病案扫描件,组织高年资病案质控医师,阅读分析QY组病例的病案、疾病分类情况、医保结算清单填写情况。分析QY组产生的原因。采用Excel 2010对数据进行统计分析。结果 (1)获取DRG实际付费医保结算清单2 810份,其中QY组病例43例,占1.53%;(2)QY病例主要分布在泌尿系肿瘤(27.91%)、神经源性膀胱(18.60%)、前列腺增生(16.28%)、输尿管疾病(11.62%)、尿道疾病(占11.62%);(3) QY组病例总住院费用为731 684.1元,次均住院费用为17 015.91元。DRG总支付金额为419 807.24元,次均支付金额为9 762.96元;(4)导致QY组病例原因:DRG分组规则缺陷14例,占32.56%;医院管理缺陷29例,占67.44%。医院管理缺陷中,医保结算清单填报缺陷13例,占30.23%;医师主要诊断或主要手术(操作)填写错误8例,占18.60%;编码员主要诊断或主要手术(操作)编码错误8例,占18.60%。结论 合理减少QY组需要优化DRG分组规则,医院加强内部管理包括提升病历内涵质量,准确分类,重视医保结算清单管理及质控,建立DRG数据质控长效机制,从而提高DRG入组准确率,积极推进医保付费改革。

Objective In order to reasonably reduce QY group and improve the accuracy of DRG,we analyzed the data of QY(ambiguity)group in the Diagnosis Related Groups in urology department of a three A and tertiary hospital.Methods Medical insurance settlement statements of urology department of a hospital in the DRG sub-platform of a municipal medical insurance bureau were collected from April 1,2022 to November 30,2022,extracting QY cases.The medical records of QY cases were extracted from the digital medical record browser of a hospital.Senior quality control physicians were organized to check medical records,disease classification and medical insurance settlement statements of QY group cases,analyzing the cases.Excel 2010 was used for statistical analysis of the data.Results①2810 copies of medical insurance settlement statements were obtained,of which 43 cases were in the QY groups,accounting for 1.53%.②The cases mainly distributed in urinary system tumors(27.91%),neurogenic bladder(18.60%),prostatic hyperplasia(16.28%),ureteral diseases(11.62%),and urethral diseases(11.62%).③The total hospitalization cost of patients in QY groups was 731684.1 yuan,and the average hospitalization cost was 17015.91 yuan.The total payment amount of DRG was 419807.24 yuan,and the average payment amount was 9762.96 yuan.④The causes of QY groups were as follows:There were 14 cases of DRG grouping rule defect,accounting for 32.56%;There were 29 cases of hospital management defects,accounting for 67.44%.Among the hospital management defects,13 cases(30.23%)of the medical insurance settlement statements were defective;There were 8 cases(18.60%)of errors in doctors’major diagnoses and major surgical operations.There were 8 cases(18.60%)of coding errors in major diagnoses and major surgical operations.Conclusion To reasonable reduction QY group,it is necessary to optimize DRG grouping rules and strengthen hospital internal management.Only by paying attention to improve the connotation quality of medical records,accurately classify disease and surgical name,strengthen the management and review of medical insurance settlement statements,and establish a long-term mechanism for DRG data quality control,we can further improve the accuracy of DRG and actively promote the reform of medical insurance payment.