In order to ameliorate the transparency of acute in-patient services in Japan, we have developed the Japanese original casemix system, so called DPC (Diagnosis Procedure Combination) after the two years’ intensive researches of other countries. This casemix system has been used for payment of acute care hospital since 2003. As the DPC system has been organized based on the already existed Fee-for-service system, its application for payment has been smoothly conducted. The introduction of DPC system has ameliorated the transparency of clinical activities and facilitated the managerial innovation of acute care hospital both at facility level and regional level. In this article, the authors would like to introduce the overview of Japanese casemix system.
Over the past 20 yr, many countries have introduced case-mix evaluation system. Some of them have fully used it for case based payment for hospital, and others partially used it for hospital payment in combined with regional health planning. The NHS countries have introduced it mainly for improving the efficiency of health system. On the contrary most of the social insurance countries have introduced it in order to control the medical expenditures, even though such expectations have not been always realized. The introduction of DRGs must be considered from the viewpoint of managerial innovation. The introduction of case-mix system has apparently changed the way of thinking and behavior of hospital managers, physicians and policy makers as well as relationships among them. The continuous innovation of information technology will further influence the case-mix based management system. This will make it possible to cover all range of health services by case-mix system in nearly future.
It is an important mission for health policy makers to assure the quality care for public. This requires some evaluation methods. The compliance level of clinical practice guidelines (CPGs) will be one of the possible tools to evaluate the quality of clinical process. However, it is not an easy task to systematically monitor the compliance level. As the Japanese DPC database gathers very detailed process information, it is possible to evaluate the CPGs compliance level. In this article, the authors would like show the usability of DPC database for process evaluation based on our previous literatures.
Under the Japanese case-mix system, so called DPC system, patient information is coded using a 14-digit code, which includes principal diagnosis and associated medical care procedures. This system can be a tool for analyzing clinical process. The clinical pathway (CP) is a management plans that provide ideal sequence of staff actions to achieve goals for patients with optimal efficiency. In this study, we collated information on medical care processes in chronological order for each patient using the DPC system, for comparative verification with the CP. The subjects included 54 laparoscopic cholecystectomy cases at Saiseikai Kumamoto Hospital between July and December 2008. We coded relevant information for medical care treatments using 20-digit DPC codes based on the original 14-digit code. The 15th digit refers to fluid administration, 16th digit antibiotic use, 17th digit blood sampling, 18th digit other examinations, 19th digit image, and 20th digit meal. We recorded information on medical care received from the date of admission to the date of discharge in chronological order using these extended DPC codes. We also created extended DPC codes for the CP and analyzed discrepancies with each patient’s extended DPC codes as variance for factor analysis. Our results have indicated that the following factors are associated with occurrence of variance cases with statistical significance: age (over 65 yr old 69.2%, under 65 yr old 43.9%; p=0.024), urgency of the admission (urgent admission 76.9%, scheduled admission 41.5%, p=0.024), inflammation (inflammation 65.0%, non-inflammation 41.2%, p=0.046). Our new method enabled to compare each patient’s individual situation with standard medical care processes specified in the CP, and visualize the actual medical care situation.