DRG為基礎前瞻性支付制度對髖關節骨折／置換術的醫療利用與照護結果之影響

Impact of the Drg-Based Prospective Payment System on Medical Utilization and Outcomes of Care for Hip Fracture and Hip Replacement

目標：為了抑制上漲的健康照護費用，美國自1983年實施診斷關聯群（diagnosis related groups，DRG）為基礎的前瞻性支付制度，台灣於2010年1月實施以TW-DRG為基礎支付制度。很少研究探討實施DRG為基礎支付制度對於醫療利用及照護結果之影響，且研究結果並不一致。本研究目的係探討TW-DRG為基礎支付制度，對於髖部骨折與髖關節置換術之醫療利用與照護結果之影響。方法：資料取自2008年至2011年全民健康保險研究資料庫全國性樣本，選取主診斷為髖部骨折或主處置為髖關節置換術予以分析。本研究使用分段廣義估計方程式，控制趨勢、病人及醫院特性，以檢測實施TW-DRG為基礎支付制度，對於住院日數、30日再住院及30日死亡之影響。結果：實施TW-DRG為基礎支付制度與住院日數減少有關，及與30日再住院呈下降趨勢有關。結論：實施DRG為基礎支付制度，造成住院日數下降與30日再住院呈現下降趨勢。DRG為基礎支付制度的推行，可能促使醫療提供者建立較佳髖部骨折與髖關節置換術照護模式，以控制醫療利用，且改善再住院率。

Objectives: To reduce rising health care costs, prospective payment systems based on diagnosis-related groups (DRGs) were introduced in the United States in 1983. Taiwan implemented the TW-DRG-based payment system in January 2010. Few studies have examined the impact of DRG-based payment systems on medical utilization and outcomes of care, and the results have been inconsistent. The objective of this study was to determine the impact of the TW-DRG-based payment system on medical use and outcomes of care for patients with hip fractures and patients undergoing hip replacement surgery. Methods: Data were derived from the nationwide sample through the National Health Insurance Research Database between 2008 and 2011. Patients admitted with a primary diagnosis of hip fracture or patients who underwent primary hip replacement surgery were selected for analysis. Segmented generalized estimating equations were used to determine the impact of the TW-DRG-based payment system on the length of stay, 30-day readmission rate, and 30-day mortality rate when adjusted for trend, patient, and hospital characteristics. Results: The implementation of the TW-DRG-based payment system was associated with a decrease in the length of stay, and with a decreasing trend in the 30-day readmission rate. Conclusions: The implementation of a DRG-based payment system in Taiwan led to a decline in the length of stay and a declining trend in the 30-day readmission rate. DRG-based payment systems might facilitate the development of a better model by which to contain medical utilization and improve readmission rates for patients with hip fractures and patients undergoing hip replacement surgery.