Association of the Swiss Diagnosis-Related Group Reimbursement System With Length of Stay, Mortality, and Readmission Rates in Hospitalized Adult Patients

Key Points

Question

Is the implementation of the Swiss diagnosis-related group reimbursement system associated with a reduction in length of hospital stay without negatively affecting in-hospital mortality and readmission rates in adult patients?

Findings

In this cohort study of data from 2 426 722 adult patients, the gradual decrease in length of hospital stay observed from 2009 to 2015 was not substantially greater after the implementation of the Swiss diagnosis-related group system in 2012. An increase in 30-day readmission rates and a decrease in in-hospital mortality were observed after the introduction of the Swiss diagnosis-related group system.

Meaning

Swiss diagnosis-related group implementation appeared to be associated with higher readmission rates and lower in-hospital mortality but not with a substantial decrease in length of hospital stays.

Abstract

Importance

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.

Objective

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.

Main Outcomes and Measures

Monthly patient-level data for LOS, in-hospital mortality, and 30-day readmission rates.

Results

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%).

Conclusions and Relevance

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.

Abstract

This cohort study examines hospitalization and patient outcomes data of hospitalized adult patients before and after the implementation of the diagnosis-related group reimbursement system in Switzerland.