Diagnosis-intervention Packet DeviationCases Medical Insurance Influencing Factors
福建医科大学启航基金 （2018QH1179）
目的：收集龙岩市某三甲医院按病种分值结算政策实施后的医疗费用相关数据，了解按病种分值付费的实施现状，对偏差病例的影响因素进行分析。方法：收集龙岩市某三甲医院2021年1-8月医保类型为龙岩市基本医疗保险的出院患者的病案首页及结算数据，共计47 177例。结算数据采用描述性统计分析；影响因素采用Logistic多元线性回归分析。结果：未转科、进入临床路径、高级别手术的患者更倾向于正常范围病例；门诊入院、非医嘱离院和有入住ICU的病人更倾向于偏差病例；医嘱转院、住院时间越长、药耗占比越高及诊断数量越多越容易倾向于超高病例；年龄大的患者更不倾向于超高病例。结论：是否转科、年龄、入院途径、住院天数、是否手术、手术级别、离院方式、临床路径、是否入住ICU、药占比、耗占比以及诊断数量是偏差病例的影响因素。
Objective：To analyze the relevant data of medical expenses after the implementation of the settlement policy by disease score in acertain grade A tertiary hospital in Longyan City，understand the implementation status of payment by disease score，and analyze the influencing factors of deviation cases. Methods：The medical records and settlement data of discharged patients whose medical insurance type was Longyan Basic Medical Insurance from January to August 2021 in acertain grade A tertiary hospital in Longyan City were collected，totaling 47，177 cases. The settlement data were analyzed by descriptive statistics. The influencing factors were analyzed by logistic multiple linear regression. Results：Patients who were not transferred to departments，entered the clinical pathway，and had high-level operations were more likely to be in the normal range. Patients admitted to outpatient clinics，discharged without doctor’s orders，and admitted to ICU were more likely to be inclined to deviation cases.Doctor’s order transfer，the higher the proportion of drug consumption and the greater the number of diagnoses，the more prone to ultra-high cases.Elder patients are less prone to ultra-high cases. Conclusions：Whether transferred，age，admission route，length of hospital stay，surgery，level of surgery，discharge method，clinical pathway，ICU admission，drug ratio，consumption ratio，and number of diagnoses are the influencing factors of deviation cases.