Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.
Division of Endocrinology, University Hospital Basel, Basel, Switzerland.
JAMA Netw Open. 2019 Feb 1;2(2):e188332. doi: 10.1001/jamanetworkopen.2018.8332.
In 2012, hospital reimbursement in Switzerland changed from a fee-for-service per diem system to a diagnosis-related group (SwissDRG) system. Whether this change in reimbursement is associated with harmful implications for quality of care and patient outcomes remains unclear.
To examine the association of the SwissDRG implementation with length of hospital stay (LOS), in-hospital mortality, and 30-day readmission rates in the overall adult inpatient population and stratified by 5 individual diagnoses.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used administrative data from the Swiss Federal Statistical Office to investigate medical hospitalizations in Switzerland from January 1, 2009, through December 31, 2015. All hospitalizations for adult medical inpatients were included in the main analysis. Patients who presented with 1 of the 5 common medical diagnoses were included in the subanalyses: community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, acute myocardial infarction, acute heart failure, and pulmonary embolism. An interrupted time series model was used to determine changes in time trends for risk-adjusted LOS, in-hospital mortality, and 30-day readmission after the implementation of SwissDRG in 2012. Analyses were performed from March 1, 2018, to June 30, 2018, and from November 1, 2018, to December 18, 2018.
Monthly patient-level data for LOS, in-hospital mortality, and 30-day readmission rates.
The sample included a total of 2 426 722 hospitalized adult patients. Of this total, 1 018 404 patients (41.9%; 531 226 [52.2%] male, median [interquartile range (IQR)] age of 69 [55-80] years) composed the before-SwissDRG period; 1 408 318 patients (58.0%; 730 228 [51.9%] male, median [IQR] age of 70 [56-81] years) composed the after-SwissDRG period. The overall LOS gradually decreased from unadjusted mean (SD) 8.0 (12.7) days in 2009 to 7.2 (17.3) days in 2015. This reduction in LOS, however, was not substantially greater with the implementation of SwissDRG in 2012 (risk-adjusted slope, -0.0166 days; 95% CI, -0.0223 to -0.0110 days), with an adjusted difference in slopes of 0.0000 days (95% CI, -0.0072 to 0.0072 days). Risk-adjusted all-cause in-hospital mortality declined from 4.9% in 2009 to 4.6% in 2015, with a substantially greater decline after implementation of SwissDRG (difference between monthly slopes before and after implementation, -0.0115%; 95% CI, -0.0190% to -0.0039%). In the same period, risk-adjusted 30-day readmission rates increased from 14.4% in 2009 to 15.0% in 2015, with a greater increase after SwissDRG implementation (change in monthly slope, 0.0339%; 95% CI, 0.0254%-0.0423%). Patients with acute myocardial infarction were found to have a substantially greater increase after SwissDRG implementation in 30-day readmission rates (adjusted difference in slopes, 0.1144%; 95% CI, 0.0617%-0.1671%).
Among medical hospitalizations in Switzerland, SwissDRG implementation appeared to be associated with an increase in readmission rates and a decrease in in-hospital mortality but not with the gradual decrease in LOS observed in the historical control period.
重要性：2012 年，瑞士的医院报销方式从按日计费的费用制改为了诊断相关组（SwissDRG）制。这种报销方式的改变是否对医疗质量和患者预后产生有害影响尚不清楚。
目的：本研究旨在调查 SwissDRG 实施与整体成年住院患者的住院时间（LOS）、院内死亡率和 30 天再入院率的相关性，并对 5 种单独诊断进行分层分析。
设计、地点和参与者：本队列研究使用瑞士联邦统计局的行政数据，对 2009 年 1 月 1 日至 2015 年 12 月 31 日期间瑞士的所有成年住院患者进行了调查。主要分析纳入了所有成年住院患者，亚组分析纳入了 5 种常见的内科诊断患者：社区获得性肺炎、慢性阻塞性肺疾病恶化、急性心肌梗死、急性心力衰竭和肺栓塞。采用中断时间序列模型确定 SwissDRG 于 2012 年实施后，风险调整 LOS、院内死亡率和 30 天再入院率的时间趋势变化。分析于 2018 年 3 月 1 日至 6 月 30 日和 2018 年 11 月 1 日至 12 月 18 日进行。
主要结局和测量指标：每月患者 LOS、院内死亡率和 30 天再入院率的数据。
结果：样本包括 2426722 名住院成年患者。其中，1018404 名患者（41.9%；531226 名[52.2%]男性，中位[四分位间距（IQR）]年龄 69[55-80]岁）为 SwissDRG 实施前组；1408318 名患者（58.0%；730228 名[51.9%]男性，中位[IQR]年龄 70[56-81]岁）为 SwissDRG 实施后组。未经调整的平均（SD）住院时间从 2009 年的 8.0（12.7）天逐渐下降至 2015 年的 7.2（17.3）天。然而，2012 年 SwissDRG 的实施并没有显著降低 LOS（风险调整斜率，-0.0166 天；95%CI，-0.0223 至-0.0110 天），调整斜率差异为 0.0000 天（95%CI，-0.0072 至 0.0072 天）。全因院内死亡率从 2009 年的 4.9%降至 2015 年的 4.6%，实施 SwissDRG 后显著下降（实施前后每月斜率差异，-0.0115%；95%CI，-0.0190%至-0.0039%）。同期，30 天再入院率从 2009 年的 14.4%上升至 2015 年的 15.0%，实施 SwissDRG 后上升幅度更大（每月斜率变化，0.0339%；95%CI，0.0254%至 0.0423%）。实施 SwissDRG 后，急性心肌梗死患者的 30 天再入院率显著增加（调整后的斜率差异，0.1144%；95%CI，0.0617%至 0.1671%）。
结论和相关性：在瑞士的内科住院治疗中，实施 SwissDRG 似乎与再入院率的增加和院内死亡率的降低有关，但与历史对照期观察到的 LOS 逐渐减少无关。
