Garber A M, Fuchs V R, Silverman J F
N Engl J Med. 1984 May 10;310(19):1231-7. doi: 10.1056/NEJM198405103101906.
To gain insight into the possible consequences of prospective payment for university hospitals, we studied 2025 admissions to the faculty and community services of a university hospital, measuring differences in case mix, costs, and mortality in the hospital. The faculty service had more of the patients with costly diagnoses, but even after adjustment for diagnosis-related groups (DRGs), costs were 11 per cent higher on the faculty service (95 per cent confidence limits, 4 to 18 per cent). The percentage differential was greatest for diagnostic costs. The differential was particularly large--70 per cent (95 per cent confidence limits, 33 to 107 per cent)--for patients with a predicted probability of death of 0.25 or greater. The in-hospital mortality rate was significantly lower on the faculty service after adjustment for case mix and patient characteristics (P less than 0.05); the difference was particularly large for patients in the high-death-risk category. Comparison of a matched sample of 51 pairs of admissions from the high-death-risk category confirmed the above results with respect to costs and in-hospital mortality, but follow-up revealed that the survival rates were equal for the two services at nine months after discharge. The effect of prospective payment on the cost of care will be closely watched; we conclude that is will also be important to monitor the effect on outcomes, including hospital mortality rates.
为深入了解大学医院实行按病种预付费制可能产生的后果，我们研究了一所大学医院教职工及社区服务部门的2025例住院病例，分析了病例组合、费用及死亡率方面的差异。教职工服务部门接收的高费用诊断患者较多，但即使在对诊断相关分组（DRGs）进行调整后，教职工服务的费用仍高出11%（95%置信区间为4%至18%）。诊断费用的百分比差异最大。对于预测死亡概率为0.25或更高的患者，差异尤为显著，高达70%（95%置信区间为33%至107%）。在对病例组合和患者特征进行调整后，教职工服务部门的住院死亡率显著较低（P<0.05）；高死亡风险类别的患者差异尤为明显。对51对高死亡风险类别的配对住院病例进行比较，证实了上述在费用和住院死亡率方面的结果，但随访显示，出院九个月后，两种服务的生存率相同。按病种预付费制对医疗费用的影响将受到密切关注；我们认为，监测其对包括医院死亡率在内的治疗结果的影响也很重要。
