1、1,DRG-principles and structure DRG原则和结构 Changchun, May 2011 长春，2011年五月 Dr. Jiri Nemec- key expert, health management 吉利核心专家，健康管理,日程Agenda,Case-mix classification systems in general病例混合分类系统 History of DRG DRG的发展历史 Principles of DRG 原理 Design of DRG 设计 Applications of DRG应用,3,Case-mix classification s
2、ystems in general 病例混合分类系统,4,医疗服务的分类系统Classification systems for health care,长期的使用的历史-如疾病的国际分类法long history of usage-e. g. International Classification of Diseases将对象或现象按照具体的属性分配到几个组（可能是重叠的）allocation of a set of objects or phenomena to several (possible overlapping) groups based on specific attribu
3、tes of the objects or the phenomena,什么是病例-混合分类系统What are case-mix classification systems,他们They 是一种提供高质量医疗服务信息的科学方法represent a scientific approach to delivery of quality information on health care,侧重于建立每个治疗病例的科学分类以及利用此信息进行医疗服务的管理focus on creation of useful classification of episodes of treatment and
4、 on utilization of this information for managing of health care provision,混合案例的分类系统Case-mix classification systems,病例的属性attributes ofa case,成本及临床的相似性 Cost & clinical similarity,相对权重relative weight,病例cases,病例混合分类系统的应用Utilization of case-mix classification systems,可以对服务的数量、服务的复杂性两个方面测量（考核）suitable mea
5、sure of volume and complexity of delivered health care对监控医疗服务质量进行风险校正risk adjustment for monitoring of quality of health care,8,History of DRG (Diagnosis Related Groups) DRG的发展历史,病例混合分类系统的按病种付费Case-mix classification system DRG-history,急性病住院的病例分类classification of cases of acute in-patient care起源于美国，
6、用于监测医院服务的利用和相关的费用（耶鲁大学，上一世纪的六十年代）originated in the US (Yale university, sixties of the last century) as a tool for monitoring of utilization of services in hospitals and of its associated costs新泽西州首次把它作为预付制the first major application as a prospective payment system (PPS) in the state New Jersey (US)
7、从1983年开始，作为预付方法在美国Medicare中使用using as PPS for all patients in the program Medicare (US) since 1983,病例混合分类系统的按病种付费Case-mix classification system DRG-history,在美国以及欧盟的应用为了used in the US and Europe for:用于对住院治疗的支付费用remuneration of in-patient care 监控医疗服务的质量以及和绩效monitoring of performance and quality of hea
8、lth care 对医院的管理management of hospitals,11,Principles of DRG DRG的原理,按诊断分组的指导原则Guiding principles of DRG,便于管理的分组数量（数百）manageable number of groups (several hundreds)每种病例被准确地分类到一个DRG组别中each case classified to exactly one DRG group划分到同一类小组的病例是临床上相似的相近的，同时治疗费用的相近的cases classified in the same group are cli
9、nically similar and represent similar costs of treatment,按诊断分组的病例特征变量Attributes of cases used for DRG classification,病人的年龄patients age主要诊断以及二次诊断main diagnosis and secondary diagnosiss是否进行了手术，如果有surgical procedure if any出院的情形way of discharging出生体重birth weight,主要诊断类别Major Diagnostic Categories,第一层次的分类
10、1st level of splitting分为约25个主要诊断类别（MDC） around 25 MDC在一个主要诊断类别的病例都是关于一个器官或者身体某一部位的病例all cases in one MDC relate to treatment of one organ or part of a body,主要诊断类别-例子Major Diagnostic Categories-examples,MDC 1 神经系统的疾病及缺陷MDC 1 Diseases and defects of nervous systemMDC 2 眼部的疾病及缺陷 MDC 2 Diseases and defe
11、cts of eyeMDC 3 耳鼻喉疾病及缺陷MDC 3 Diseases and defects of ear, mouth, nose, throatMDC 4 呼吸系统的疾病及缺陷MDC 4 Diseases and defects of respiratory systemMDC 5 循环系统的疾病及缺陷 MDC 5 Diseases and defects of circulatory system,按病种付费的基本组Base DRG groups,第二层面约300个按病种付费组around 300 base DRG groups根据治疗或一些相关的主要诊断被分到上述的按诊断分类中
12、all cases in one base DRG relate to treatment of one or several related main diagnosisor 或则按几个相关的手术治疗分到诊断分类中or several related surgical procedures,诊断分组的基本组-例子Base DRG groups-examples,MDC 4 呼吸系统的疾病及缺陷MDC 4 Diseases and defects of respiratory system基于0438哮喘和支气管炎 Base 0438 Asthma and bronchiolitis 根据IC
13、D-10诊断J45,J46,J41,J21, J98 diagnosis J45,J46,J41,J21, J98 according to ICD-10基于0401的大胸部手术 Base 0401 Big chest procedures,按病种付费组DRG groups（按基本组再细分）,第三层面近900个按诊断分组的组around 900 DRG groups一个基本组按照第二诊断（次要诊断）（通常）被分为三组a base group splits according to secondary diagnosis to (usually) three DRG groups 不包括并发症和
14、其它疾病的发生without Complications and Comorbidity (CC) 包括并发症和其它疾病的发生with CC 包括主要的并发症和其它疾病的发生with major CC,按诊断分组-例子DRG groups-examples,MDC 4 呼吸系统的疾病和缺陷Diseases and defects of respiratory system0438 的哮喘病和支气管炎基本组 Base 0438 Asthma and bronchiolitis 根据ICD-10诊断J45,J46,J41,J21, J98 diagnosis J45,J46,J41,J21, J9
15、8 according to ICD-10按诊断分组04381，不包括CC的哮喘病和支气管炎DRG group 04381 Asthma and bronchiolitis without CC按诊断分组04382，包括CC的哮喘病和支气管炎DRG group 04382 Asthma and bronchiolitis with CC按诊断分组04383，包括主要的CC哮喘病和支气管炎DRG group 04383 Asthma and bronchiolitis with major CC,按诊断分组的决策图表Decision tree of the DRG,MDC 1,MDC 2,MDC
16、 n,内科medical groups,ne,主要的诊断 What main diagnosis?,手术流程Surgical procedure ?,主要的诊断 What main diagnosis?,重要的第二诊断 Important secondary diagnosiss?,手术组surgical groups,具体手术？What procedure?,medical groups without CC,medical groups withCC,如何对医院的病例进行分类How to classify hospital cases ?,依靠一种叫做GROUPER的软件by means
17、of a software called GROUPER输入：主要诊断（第一诊断），次要诊断（第二诊断），手术编码，病人年龄，出院编码，出生体重input: main diagnosis, secondary diagnosiss, code of surgical procedure, age of patient, code of discharge, birth weight输出：合理的按病种付费分组代码output: code of an appropriate DRG group,Example of a grouper (IR DRG) DRG分组器（软件）（online mode
18、l在线模式）,23,Design of DRG DRG的设计,24,DRG与临床路径 DRG versus clinical pathways,DRG Clustering 病例的分类、分组 clinical assessment by a panel of professionals 由专业人员小组进行临床评估 statistical evaluation 统计分析评价clinical pathways 临床路径clinical assessment by a panel of professionals由专业人员小组进行临床评估,Statistical measure of homogen
19、eity 对同质性的统计测量指标,方差系数（变异系数） Coefficient of variance is mostly used (CV):,SUM (yi -Ag)2,CV =,1 n-1,-,-,SUM yi,-,n, 1.0,对分组效果的统计指标 Statistical measure of effectiveness of grouping,方差缩小系数Reduction of variance is mostly used (R2):,27,建立DRG的原则 Rules for construction of DRG groups (1),DRG组的数量合理reasonable
20、number of DRG groups分到同组的具有同质性（方差系数1）homogeneity of DRG groups(coefficient of variance should be less than 1)每一个DRG组都有足够的数量（至少200个病例）sufficient number of cases in one DRG group (more than 200 cases),28,Rules for construction of DRG groups (2),随着往下分，方差缩小系数的下降应至少5%splitting of a DRG group should resul
21、t in a reduction of variance of at least 5 % calculated on cases in the respective groups 属于同一个基本组，但为不同DRG组的平均住院日之差应该至少2天（或费用的差别=100%）distance of LOS between DRG groups belonging to one base group should be 2 days at least (or by 100 % more costly)90%可信限没有重叠90 % confidence intervals should be disjun
22、ctive,29,分组的效果Effectiveness of grouping,1.,不同分组水平下的方差系数 Values of R2 when applied on different levels of grouping according to DRG1:,1 APR-DRG applied on hospital cases from US hospitals,30,Applications of DRG DRG的应用,What does DRG allow? DRG能够做什么,to understand and to describe production of hospitals
23、了解和描述医院的产品this is a precondition for an assessing of costs of the production of hospitals这是评估医院产品成本的先决条件,How can be DRG system used ?如何运用DRG系统,for a prospective payment of individual hospital cases对于医院个体病例的预期支付 for qualification of global budgets for hospitals对医院整体预算的限制 for assessment of hospital invoices and/or of quality of acute in-patient care对医院账单的评估和/或急诊住院医疗的质量 for managing of hospitals对医院的管理,33,谢 谢 Thanks for attention,
