DRG支付背景下临床科室超支情况分析及管理策略——以某三级综合医院心血管内科为例  

Analysis and management strategy of clinical departments over⁃expenditure under the DRG payment background:taking Department of Cardiovascular Medicine from a classⅢcomprehensive hospital as an example

作　　者：叶娟[1] 金卉[1] 曾冠玉 何青[1] 何彬婵 蒋丽萍 陈密思 YE Juan;JIN Hui;ZENG Guanyu;HE Qing;HE Binchan;JIANG Liping;CHEN Misi(Medical Insurance Section,the Second Affiliated Hospital of Guangxi Medical University,Nanning 530007,Guangxi,China)

机构地区：[1]广西医科大学第二附属医院医疗保险科,广西南宁市530007

出　　处：《广西医学》2024年第6期889-894,共6页Guangxi Medical Journal

基　　金：广西壮族自治区卫生健康委员会自筹经费科研课题(Z20201129,Z‑A20220668);广西高校中青年教师科研基础能力提升项目(2021KY0072)。

摘　　要：目的分析临床科室疾病诊断相关分组(DRG)结算病例超支的影响因素,为科室精细化管理提供思路。方法选取2022年某三级综合医院心血管内科1495例DRG结算病例的医保结算信息、病案信息及费用信息,使用单因素分析及多因素Logistic回归模型分析DRG结算病例超支的影响因素。结果单因素分析结果显示,结余病例组和超支病例组在年龄、住院天数、医保类型、病例类型、疾病严重程度、治疗操作类型、相对权重(RW),以及药品占比、耗材占比、检查检验占比、医疗服务占比方面的差异具有统计学意义(P<0.05)。多因素Logistic回归分析结果显示,住院天数≥5 d、城乡居民医保、低倍率或高倍率病例、高药品占比、高耗材占比是DRG结算病例超支的危险因素(P<0.05),非手术室操作、RW≥2是DRG结算病例超支的保护因素(P<0.05)。结论临床科室可从主动适应医保规则,落实临床路径管理,加强医疗成本控制,兼顾学科高质量发展等方面持续改进,促进DRG精细化管理,助力医院可持续发展。Objective To analyze the influencing factors for over‑expenditure of cases in clinical departments'diagnosis related groups(DRG)settlement,and to provide ideas for the departments'delicacy management.Methods Medical insurance settlement information,medical record information,and expense information of 1495 cases with DRG settlement in Department of Cardiovascular Medicine from a classⅢcomprehensive hospital in 2022 were selected.The univariate analysis and multivariate Logistic regression model were used to analyze the influencing factors for over‑expenditure of cases with DRG settlement.Results The results of univariate analysis revealed that there were statistically significant differences in age,length of hospital stays,medical insurance type,case type,disease severity,type of therapeutic operation,relative weight(RW),and proportions of drugs,consumptive materials,examination and tests,and medical service between the balance case group and the over‑expenditure group(P<0.05).The results of multivariate Logistic regression analysis revealed that length of hospital stays≥5 days,medical insurance for urban and rural residents,low or high magnification cases,high drugs proportion,and high proportion of consumptive materials were the risk factors for over‑expenditure of cases with DRG settlement(P<0.05),whereas non‑operating room operation,RW≥2 were the protective factors for over‑expenditure of cases with DRG settlement(P<0.05).Conclusion Clinical departments can actively adapt to medical insurance rules,implement clinical path management,strengthen medical expenditure control,take into account the high-quality development of disciplines and other aspects of continuous improvement,promote DRG delicacy management,and help the sustainable development of hospitals.

关 键 词：疾病诊断相关分组 结算病例超支 影响因素 运营管理 临床科室 

分 类 号：R197.3[医药卫生—卫生事业管理]