The Application Of The Case Clinical Complex (ECC) Model In The DRGs Grouper

DRGs(Diagnosis Related Groups)is a scientific case mix method.The prospective payment system and medical quality evaluation system based on the DRGs are able to control the unreasonable medical expenses and improve the efficiency of management.The design of DRGs program is the core of DRGs system,and the complexity of episodes is closely related to the grouping of episodes.Episode Clinical Complexity model is used to measure the complexity of episodes.Studying the Episode Clinical Complexity model and optimizing the method of calculating the complexity of episodes can refine the structure of DRGs program.And it also has great realistic significance in medicare payments and medical performance measurement.Objective:To explore the application of Episode Clinical Complexity model in DRGs program.To explore the algorithm of the episode complexity in China which can provide the foundation for the establishment of episode complexiety systems.To explore the feasibility of implementing the Episode Clinical Complexity model in the DRGs program.Method:The study adopts case study method to explore the application of Episode Clinical Complexity model in DRGs program.It takes the patient data from a public third-grade class-A hospital in Beijing as a case,to explore the algorithm of the episode complexity in China through the theory of the model.The classification use the decision tree model which is based on classification and regression tree(CART)algorithm to split the inpatient cases belonging to the same group of adjacent DRGs(gastroscopy or treatment operations)using the value calcuclated by the model.Comparative approach is also put to use to compare the performance of classification between whether or not implementing the model in the DRGs program,and it evaluates the results through statistics indicator and method,such as coefficient of variation(CV),reduction in variance(RIV)and nonparametric test.Content:1 Analyze the theoretical basis of the DRGs program and the Episode Clinical Complexity model,make clear of the process of model in DRGs program,and discuss the scientific meaning of the model.2 Taking the patient data from a hospital which classified in "gastroscopy or treatment operations" as a sample to explore the algorithm of the episode complexity in China based on the theory of the Model.3 Implementing the Episode Clinical Complexity model in the DRGs in China and grouping the episode sample.Evaluate the rationality of model grouped results by comparing with the results of CN-DRGs program,and analyze the impact of the Episode Clinical Complexity model in the DRGs program.Result:1.Episode Clinical Complexity model has a scientific theoretical foundtation and measures of the complexity of cases comprehensivly.The model allows for the assignment an Episode Clinical Complexity Score(ECCS)to each episode which means the complexity value of cases.These scores quantify relative levels of resource utilisation within each Adjacent Diagnosis Related Group,which calculated from diagnosis complexity level of each diagnosis.2.Based on the information and data of "gastroscopy or treatment operations" inpatients from sample hospital,the study realize the calculation of complexity of cases in our country,with a result of 266 diagnosis' complexity level and 348 Episode Clinical Complexity Score.Grouping the episodes based on the ECCS finally formats three groups.3.The results of the episode groups were evaluated through statistical methods.It shows that the coefficient variation(CV)of the costs data from three case groups are less than 0.51,and the homogeneity of the grouping is perfect;reduction in variance value(RIV)is 0.81,so the heterogeneity between groups is strong;and nonparametric Kruskal-Wallis tests shows the differences of costs has statistically significance in three sets.Compared to the original DRGs grouped results,the outcome of implementing the Episode Clinical Complexity Score demonstrates better grouping performance.Conclusion:Episode Clinical Complexity model can distinguish the level of medical resources consumption,which reflects the complexity of the episode.The research format the algorithm of the episode complexity in China,and also verify the theoretical science and feasibility of Episode Clinical Complexity model.The results which applying the model in DRGs program show better grouping performance.Episode Clinical Complexity model provides a way to refine the DRGs program in China,so it has a broad prospect of application.It is necessary to introduce the ECC model in our country's DRGs program to enhance grouping effectiveness,and promote the development of DRGs in the health management field.