Assaf A R, Lapane K L, McKenney J L, Carleton R A
Pawtucket Heart Health Program, Memorial Hospital of Rhode Island, Pawtucket.
N Engl J Med. 1993 Sep 23;329(13):931-5. doi: 10.1056/NEJM199309233291307.
The prospective payment system, under which diagnosis-related groups (DRGs) are used to reimburse hospitals for the care of Medicare patients, replaced the fee-for-service method of payment in Rhode Island in 1983 and in Massachusetts in 1985. Changes in financial incentives resulting from the use of the DRG system may have influenced the assignment of discharge diagnostic codes away from those with lower reimbursement toward codes with higher reimbursement.
We collected data from the hospital records of patients 35 through 74 years of age who were discharged with codes 410 through 414 (representing various categories of coronary heart disease) of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The patients were discharged from seven hospitals in two New England communities (one in Rhode Island and one in Massachusetts) between 1980 and 1988. The rates of diagnosis of various forms of coronary heart disease were determined by studying ICD-9-CM hospital discharge codes (codes 410 and 411 for acute forms of coronary heart disease and codes 412, 413, and 414 for chronic forms) and by using a computerized diagnostic algorithm designed to detect definite myocardial infarction and fatal coronary heart disease.
The rates of definite coronary events diagnosed by the algorithm and by the study of ICD-9-CM codes 410 through 414 were constant or increased slightly during the study period. However, the frequency of assignment of codes for the acute forms of coronary heart disease (which entail higher reimbursement) rose from 35.2 percent to 48.4 percent among discharged patients with cardiac disease after the institution of DRGs. The majority of this increase was associated with the code for unstable angina pectoris. The frequency of assignment of codes for the chronic forms of coronary heart disease (which entail lower reimbursement) decreased reciprocally, from 64.8 percent to 51.6 percent (P < 0.001).
Our data are consistent with the hypothesis that the prospective reimbursement system has influenced the assignment of hospital discharge codes in a way that would increase payment to hospitals. However, the data do not permit us to distinguish whether hospitals began to assign more precise diagnoses with the advent of the DRG system, or whether they began to favor diagnoses of acute conditions solely for financial reasons.
按疾病诊断相关分组（DRGs）对医疗保险患者的医疗费用进行医院报销的前瞻性支付系统，于1983年在罗德岛州、1985年在马萨诸塞州取代了按服务收费的支付方式。使用DRG系统所导致的财务激励变化，可能影响了出院诊断编码的分配，使其从报销较低的编码转向报销较高的编码。
我们从年龄在35至74岁、出院时使用《国际疾病分类》第九版临床修订本（ICD - 9 - CM）中410至414编码（代表各类冠心病）的患者的医院记录中收集数据。这些患者于1980年至1988年期间从新英格兰两个社区的七家医院出院（一家在罗德岛州，一家在马萨诸塞州）。通过研究ICD - 9 - CM医院出院编码（急性冠心病形式的编码为410和411，慢性冠心病形式的编码为412、413和414）以及使用旨在检测明确心肌梗死和致命冠心病的计算机化诊断算法，确定各种形式冠心病的诊断率。
在研究期间，通过算法以及对ICD - 9 - CM编码410至414的研究确定的明确冠心病事件发生率保持不变或略有上升。然而，在实施DRGs后，出院的心脏病患者中，急性冠心病形式（报销较高）编码的分配频率从35.2%升至48.4%。这种增加的大部分与不稳定型心绞痛编码相关。慢性冠心病形式（报销较低）编码的分配频率相应下降，从64.8%降至51.6%（P < 0.001）。
我们的数据与以下假设一致，即前瞻性报销系统以增加医院支付的方式影响了医院出院编码的分配。然而，这些数据不允许我们区分是医院随着DRG系统的出现开始分配更精确的诊断，还是仅仅出于财务原因开始倾向于急性病症的诊断。
