Impacts of Hospital Payment Based on Diagnosis Related Groups (DRGs) with Global Budget on Resource Use and Quality of Care: A Case Study in China.

BACKGROUND: China has implemented numerous pilots to shift its hospital payment mechanism from the traditional retrospective cost-based system to prospective diagnosis-related-group (DRG) -based system. This study investigated the impact of the DRG payment reform with global budget in Zhongshan, China. METHODS: A total of 2895 patients diagnosed with acute myocardial infarction (AMI) were selected from local two largest tertiary hospitals, among which 727 were discharged prior to the payment reform and 2168 afterwards. Difference-in-difference (DID) regression models were used to evaluate the policy effects on patients' percutaneous coronary intervention (PCI) use, hospital expenditures, in-hospital mortality, and readmission rates within 30 days after discharge. RESULTS: Patients' PCI use and hospital expenditures increased quickly after the payment reform. With patients with no local insurance scheme as reference, PCI use for local insured patients decreased significantly by 4.55 percent (95 percent confidence interval [CI]: 0.23, 0.72), meanwhile the total hospital expenses decreased significantly by US$986.10 (b=-0.15, P=0.0037) after reform. No changes were observed with patients' hospital mortality and readmission rates in our study. CONCLUSION: The innovative DRG-based payment reform in Zhongshan suggested a positive effect on AMI patient's cost containment but negative effect on encouraging resource use. It had no impacts on patients' care quality. Cost shifting consequence from the insured to the uninsured was observed. More evidence of the impacts of the DRG-based payment in China's health scenario is needed before it is generalized nationwide.

Inappropriate hospital days of a tertiary hospital in Shanghai, China.

OBJECTIVE: This study aims to evaluate the prevalence of inappropriate hospital stays in a tertiary hospital in Shanghai, identify the causes for the inappropriateness and analyze the predictors. DESIGN: A retrospective review of medical records. SETTING: The cardiology and the orthopedics departments of a tertiary hospital in Shanghai, China. PARTICIPANTS: About 806 patients discharged from the cardiology or the orthopedics department of a tertiary hospital from March 2013 to February 2014. INTERVENTIONS: Two reviewers audited 8396 hospital days of the cardiology department (n = 3606) and the orthopedics department (n = 4790) by adopting the Chinese Version of the Appropriateness Evaluation Protocol. Univariate and multivariate analysis were adopted to identify the predictors of higher levels of inappropriateness produced by internal causes. MAIN OUTCOME MEASURE: The prevalence of inappropriate hospital days. RESULTS: It was found that 910 (25.2%) and 1940 (40.5%) hospital days were judged to be inappropriate in the cardiology and the orthopedics departments, respectively; and 753 (20.9%) and 1585 (33.1%) of these inappropriate hospital days were due to internal reasons, respectively. Awaiting tests, surgery or discharge were determined to constitute the main causes of inappropriateness for both departments. The predictors of higher levels of inappropriateness in the cardiology department were younger age, self-pay, outpatient admission and inappropriate admission. Self-pay, surgical and/or first-time admission patients exhibited the highest levels of inappropriateness in the orthopedics department. CONCLUSIONS: The rates of inappropriateness in the involved departments were relatively high. Further interventions should be designed and implemented, accordingly.

Reliability and Validity of the Chinese Version Appropriateness Evaluation Protocol.

OBJECTIVE: To adapt the Appropriateness Evaluation Protocol (AEP) to the specific settings of health care in China and to validate the Chinese version AEP (C-AEP). METHODS: Forward and backward translations were carried out to the original criteria. Twenty experts participated in the consultancy to form a preliminary version of the C-AEP. To ensure applicability, tests of reliability and validity were performed on 350 admissions and 3,226 hospital days of acute myocardial infraction patients and total hip replacement patients in two tertiary hospitals by two C-AEP reviewers and two physician reviewers. Overall agreement, specific agreement, and Cohen's Kappa were calculated to compare the concordance of decisions between pairs of reviewers to test inter-rater reliability and convergent validity. The use of "overrides" and opinions of experts were recorded as measurements of content validity. Face validity was tested through collecting perspectives of nonprofessionals. Sensitivity, specificity, and predictive values were also reported. RESULTS: There are 14 admission and 24 days of care criteria in the initial version of C-AEP. Kappa coefficients indicate substantial agreement between reviewers: with regard to inter-rater reliability, Kappa (κ) coefficients are 0.746 (95% confidence interval [CI] 0.644-0.834) and 0.743 (95% CI 0.698-0.767) of admission and hospital days, respectively; for convergent validity, the κ statistics are 0.678 (95% CI 0.567-0.778) and 0.691 (95% CI 0.644-0.717), respectively. Overrides account for less than 2% of all judgments. Content validity and face validity were confirmed by experts and nonprofessionals, respectively. According to the C-AEP reviewers, 18.3% of admissions and 28.5% of inpatient days were deemed inappropriate. CONCLUSIONS: The C-AEP is a reliable and valid screening tool in China's tertiary hospitals. The prevalence of inappropriateness is substantial in our research. To reduce inappropriate utilization, further investigation is needed to elucidate the reasons and risk factors for this inappropriateness.