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Article(id=1322607971469743064, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1322607837742747790, articleNumber=null, orderNo=null, doi=10.20043/j.cnki.MPM.202506228, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1749744000000, receivedDateStr=2025-06-13, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1793263913266, onlineDateStr=2026-10-29, pubDate=1761321600000, pubDateStr=2025-10-25, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793263913266, onlineIssueDateStr=2026-10-29, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793263913266, creator=13701087609, updateTime=1793263913266, updator=13701087609, issue=Issue{id=1322607837742747790, tenantId=1146029695717560320, journalId=1227665162245664772, year='2025', volume='52', issue='20', pageStart='3649', pageEnd='3840', issueExtLink='null', onlineDate='null', pubDate='1761321600000', pubDateStr='2025-10-25', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793263881383, creator='13701087609', updateTime=1793264238791, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1322609336933794638, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1322607837742747790, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1322609336933794639, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1322607837742747790, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=3767, endPage=3773, ext={EN=ArticleExt(id=1322607971834647513, articleId=1322607971469743064, tenantId=1146029695717560320, journalId=1227665162245664772, language=EN, title=Cost structure comparison of DAMA and DC patients under the DRG model, columnId=1228016567846367388, journalTitle=Modern Preventive Medicine, columnName=Health Policy and Management, runingTitle=null, highlight=null, articleAbstract=
Objective

To analyze the differences in inpatient cost structure and variation between patients discharged against medical advice (DAMA) and those discharged per medical advice (DC) under the DRG payment model, aiming to support resource optimization and risk communication strategies.

Methods

Front-page medical records of all DAMA and DC inpatients from a tertiary general hospital between 2020 and 2024 were collected. Descriptive statistics and univariate analysis were used to compare cost differences. Cluster analysis and structural variation degree analysis were conducted to examine cost composition and annual variation trends.

Results

Significant differences were found between the two groups in total and itemized inpatient costs. DAMA patients exhibited a “majority low-cost, minority high-expenditure” pattern, dominated by drug expenses and relatively low treatment costs. In contrast, DC patients showed more balanced cost distribution with stable proportions of diagnostic, treatment, and drug costs. Structural variation analysis indicated greater variation among DC patients, driven by changes in treatment and general medical service fees, while DAMA patients were mainly affected by diagnostic cost fluctuations.

Conclusion

Medical institutions should prioritize optimizing the cost structure of DAMA patients to enhance resource allocation and cost control, promoting standardized clinical practice and effective use of medical insurance funds under DRG reform.

, authors=Jie ZHANG1, 2, Chun-xia YANG1, authorsList=Jie ZHANG, Chun-xia YANG, authorCompany=null, correspAuthors=Chun-xia YANG, authorNote=null, correspAuthorsNote=null, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322607972371518428, articleId=1322607971469743064, tenantId=1146029695717560320, journalId=1227665162245664772, language=CN, title=DRG模式下不同离院方式住院费用结构差异研究, columnId=1228016568014139551, journalTitle=现代预防医学, columnName=卫生政策与管理, runingTitle=null, highlight=null, articleAbstract=
目的

在DRG支付模式下，分析非医嘱离院（DAMA）与医嘱离院（DC）患者住院费用构成及其变动特征，为优化资源配置和完善风险告知提供依据。

方法

选取某三甲医院2020—2024年全部DAMA与DC患者的病案首页数据，采用描述性统计与单因素分析比较两组费用差异，并应用聚类分析和结构变动度分析，探讨费用构成特征及其年度变动趋势。

结果

DAMA与DC患者在住院总费用及各项费用上差异均具统计学意义。DAMA患者呈现“多数低费用、少数高支出”的特征，以药品支出为主，治疗费用较低；DC患者费用分布更均衡，比例结构较合理。结构变动度分析显示, DC患者费用结构变动幅度高于DAMA，前者受治疗费和综合医疗服务费驱动，后者则主要受诊断费用波动影响。

结论

应重点优化DAMA患者费用结构，提升资源配置效率和控费水平，促进诊疗行为规范化，助力实现DRG改革目标。

, authors=张洁1, 2, 杨春霞1, authorsList=张洁, 杨春霞, authorCompany=null, correspAuthors=杨春霞, authorNote=

张洁（1994—），女，硕士在读，统计师，研究方向：流行病学与卫生统计学

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杨春霞，E-mail:
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张洁（1994—），女，硕士在读，统计师，研究方向：流行病学与卫生统计学

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(In Chinese), articleTitle=Practice and reflection on the integration management of clinical pathways and C-DRG collection and payment, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1322607972577039325, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, xref=1., ext=[AuthorCompanyExt(id=1322607972593816542, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, companyId=1322607972577039325, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Department of Epidemiology and Health Statistics, West China School of Public Health/west China Fourth Hospital, Sichuan University, Chengdu, Sichuan 610041, China), AuthorCompanyExt(id=1322607972602205151, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, companyId=1322607972577039325, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1.四川大学华西公共卫生学院/华西第四医院流行病与卫生统计学系，四川　成都　610041)]), AuthorCompany(id=1322607972673508320, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, xref=2., ext=[AuthorCompanyExt(id=1322607972686091233, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, companyId=1322607972673508320, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2.昆明市第一人民医院医务部（病案管理)])], figs=[ArticleFig(id=1322607975940871161, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=EN, label=Fig.1, caption=CLARA Cluster Analysis of Hospitalization Costs in DAMA vs. DC Patients and Composition Comparison Across Clusters, figureFileSmall=E9Sx62DUIvX7TxSiL+MzVA==, figureFileBig=mi9ZG2FyEzkmmXkTl0S1TA==, tableContent=null), ArticleFig(id=1322607976007980026, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=CN, label=图1, caption=DAMA与DC患者住院费用CLARA聚类图及各聚类组住院费用构成对比图, figureFileSmall=E9Sx62DUIvX7TxSiL+MzVA==, figureFileBig=mi9ZG2FyEzkmmXkTl0S1TA==, tableContent=null), ArticleFig(id=1322607976213500923, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=EN, label=Table 1, caption=

Descriptive and comparative analysis of hospitalization costs and length of stay between DAMA and DC patients

, figureFileSmall=null, figureFileBig=null, tableContent=
组别M（IQR）U值Z值P值
DAMADC
住院总费用（元）6 176.90（10 115.13）7 429.36（7 106.73）4 114 103 323.000-33.145<0.001
自付费用（元）1 959.81（4 920.85）2 270.64（5 648.62）4 582 988 948.500-6.317<0.001
综合医疗服务费（元）970.36（1 629.58）1 144.69（1 153.37）4 219 325 698.500-27.114<0.001
诊断费（元）2 809.02（3 626.43）2 739.00（2 899.88）4 540 691 865.500-8.697<0.001
治疗费（元）25.76（686.95）279.29（1 996.52）3 900 009 450.500-45.642<0.001
药费（元）1 281.14（3 608.06）1 474.81（2 564.91）4 530 406 470.000-9.286<0.001
其他费用（元）95.17（407.80）132.72（683.41）4 189 938 927.500-28.799<0.001
实际住院天数（天）5.00（6.00）7.00（5.00）3 487 715 537.000-69.267<0.001
), ArticleFig(id=1322607976268026876, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=CN, label=表1, caption=

DAMA与DC患者住院费用及住院日的描述性分析及差异性分析

, figureFileSmall=null, figureFileBig=null, tableContent=
组别M（IQR）U值Z值P值
DAMADC
住院总费用（元）6 176.90（10 115.13）7 429.36（7 106.73）4 114 103 323.000-33.145<0.001
自付费用（元）1 959.81（4 920.85）2 270.64（5 648.62）4 582 988 948.500-6.317<0.001
综合医疗服务费（元）970.36（1 629.58）1 144.69（1 153.37）4 219 325 698.500-27.114<0.001
诊断费（元）2 809.02（3 626.43）2 739.00（2 899.88）4 540 691 865.500-8.697<0.001
治疗费（元）25.76（686.95）279.29（1 996.52）3 900 009 450.500-45.642<0.001
药费（元）1 281.14（3 608.06）1 474.81（2 564.91）4 530 406 470.000-9.286<0.001
其他费用（元）95.17（407.80）132.72（683.41）4 189 938 927.500-28.799<0.001
实际住院天数（天）5.00（6.00）7.00（5.00）3 487 715 537.000-69.267<0.001
), ArticleFig(id=1322607976335135741, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=EN, label=Table 2, caption=

Structure of hospitalization costs for different clusters of DAMA patients (Unit: CNY)

, figureFileSmall=null, figureFileBig=null, tableContent=
聚类组人数[n(%)]住院总费用综合医疗服务费诊断费治疗费药费其他费用
17 106（27.52）1 882.35378.861 019.5192.08338.2853.62
28 061（31.22）5 377.56891.802 577.77399.981 253.96254.05
36 078（23.54）11 640.641 838.404 633.50665.093 675.88827.77
43 965（15.36）35 842.355 103.368 626.072 261.7013 885.615 965.61
5610（2.36）167 012.1721 270.6526 543.5312 904.5069 005.5937 287.90
), ArticleFig(id=1322607976410633214, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=CN, label=表2, caption=

DAMA患者不同聚类的住院费用结构（单位：元）

, figureFileSmall=null, figureFileBig=null, tableContent=
聚类组人数[n(%)]住院总费用综合医疗服务费诊断费治疗费药费其他费用
17 106（27.52）1 882.35378.861 019.5192.08338.2853.62
28 061（31.22）5 377.56891.802 577.77399.981 253.96254.05
36 078（23.54）11 640.641 838.404 633.50665.093 675.88827.77
43 965（15.36）35 842.355 103.368 626.072 261.7013 885.615 965.61
5610（2.36）167 012.1721 270.6526 543.5312 904.5069 005.5937 287.90
), ArticleFig(id=1322607976477742079, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=EN, label=Table 3, caption=

Structure of hospitalization costs for different clusters of DC patients (Unit: CNY)

, figureFileSmall=null, figureFileBig=null, tableContent=
聚类组人数[n(%)]住院总费用综合医疗服务费诊断费治疗费药费其他费用
161 597（16.95）2 709.57636.991 235.87220.71541.7674.24
2133 366（36.69）7 058.561 064.451 936.801 486.521 502.281 068.51
3118 224（32.53）10 051.091 721.024 521.13356.503 066.25386.19
432 801（9.02）34 944.954 844.488 361.653 215.4913 076.115 447.22
517 485（4.81）43 327.612 203.843 938.015 626.224 003.3427 556.20
), ArticleFig(id=1322607976553239552, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=CN, label=表3, caption=

DC患者不同聚类的住院费用结构（单位：元）

, figureFileSmall=null, figureFileBig=null, tableContent=
聚类组人数[n(%)]住院总费用综合医疗服务费诊断费治疗费药费其他费用
161 597（16.95）2 709.57636.991 235.87220.71541.7674.24
2133 366（36.69）7 058.561 064.451 936.801 486.521 502.281 068.51
3118 224（32.53）10 051.091 721.024 521.13356.503 066.25386.19
432 801（9.02）34 944.954 844.488 361.653 215.4913 076.115 447.22
517 485（4.81）43 327.612 203.843 938.015 626.224 003.3427 556.20
), ArticleFig(id=1322607976611958784, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=EN, label=Table 4, caption=

Top 5 DRG groups in cluster 1 of DAMA patients

, figureFileSmall=null, figureFileBig=null, tableContent=
DRGs组DRGs组名称DRGs权重人数（占比,%）平均住院天数（天）平均住院费用（元）日均住院费用（元）
ES33呼吸系统感染/炎症，伴并发症或合并症0.368 0105（3.13）4.662 371.24509.16
DT19中耳炎及上呼吸道感染0.225 192（2.74）3.481 948.70560.25
ES35呼吸系统感染/炎症，不伴并发症或合并症0.272 079（2.35）3.672 061.02561.45
DS19平衡失调及听觉障碍0.426 171（2.11）3.731 978.64530.13
GZ15其他消化系统诊断，不伴并发症或合并症0.311 359（1.76）2.271 409.00620.38
), ArticleFig(id=1322607976695844865, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=CN, label=表4, caption=

DAMA患者cluster1中前五的DRGs组情况

, figureFileSmall=null, figureFileBig=null, tableContent=
DRGs组DRGs组名称DRGs权重人数（占比,%）平均住院天数（天）平均住院费用（元）日均住院费用（元）
ES33呼吸系统感染/炎症，伴并发症或合并症0.368 0105（3.13）4.662 371.24509.16
DT19中耳炎及上呼吸道感染0.225 192（2.74）3.481 948.70560.25
ES35呼吸系统感染/炎症，不伴并发症或合并症0.272 079（2.35）3.672 061.02561.45
DS19平衡失调及听觉障碍0.426 171（2.11）3.731 978.64530.13
GZ15其他消化系统诊断，不伴并发症或合并症0.311 359（1.76）2.271 409.00620.38
), ArticleFig(id=1322607976771342338, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=EN, label=Table 5, caption=

Top 5 DRG groups in cluster 1 of DC patients

, figureFileSmall=null, figureFileBig=null, tableContent=
DRGs组DRGs组名称DRGs权重人数（占比，%）平均住院日（天）平均住院费用（元）日均住院费用（元）
AH11有创呼吸机支持≥96小时或ECMO或全人工心脏移植术，伴严重并发症或合并症7.053 355（22.27）35.60175 807.934 938.43
HJ11与肝、胆或胰腺疾患有关的其他手术，伴严重并发症或合并症4.628 512（4.86）23.67156 873.146 628.44
BE29脑血管介入治疗11.436 210（4.05）16.70146 055.398 745.83
FK39永久性起搏器/除颤器置入/置换/更新5.483 88（3.24）14.88163 299.7010 978.13
GC11食管、胃、十二指肠其他手术，伴严重并发症或合并症2.874 65（2.02）14.60138 550.139 489.74
), ArticleFig(id=1322607976884588547, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=CN, label=表5, caption=

DAMA患者cluster5中前五的DRGs组情况

, figureFileSmall=null, figureFileBig=null, tableContent=
DRGs组DRGs组名称DRGs权重人数（占比，%）平均住院日（天）平均住院费用（元）日均住院费用（元）
AH11有创呼吸机支持≥96小时或ECMO或全人工心脏移植术，伴严重并发症或合并症7.053 355（22.27）35.60175 807.934 938.43
HJ11与肝、胆或胰腺疾患有关的其他手术，伴严重并发症或合并症4.628 512（4.86）23.67156 873.146 628.44
BE29脑血管介入治疗11.436 210（4.05）16.70146 055.398 745.83
FK39永久性起搏器/除颤器置入/置换/更新5.483 88（3.24）14.88163 299.7010 978.13
GC11食管、胃、十二指肠其他手术，伴严重并发症或合并症2.874 65（2.02）14.60138 550.139 489.74
), ArticleFig(id=1322607976951697412, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=EN, label=Table 6, caption=

Structural change value and degree of change (%) in hospitalization costs, 2020—2024

, figureFileSmall=null, figureFileBig=null, tableContent=
项目DAMA
2020—20212021—20222022—20232023—20242020—2024
综合医疗服务费0.060.730.730.522.04
诊断费1.031.860.12-6.08-3.06
治疗费0.000.21-0.010.020.21
药费-0.34-4.20-0.96-1.50-7.00
其他费用-0.34-0.32-0.25-0.18-0.78
结构变动度1.787.332.078.3013.10
项目DC
2020—20212021—20222022—20232023—20242020—2024
综合医疗服务费0.070.430.381.282.15
诊断费0.880.16-1.31-1.75-2.03
治疗费0.360.35-0.402.082.39
药费-2.00-3.81-1.31-1.84-8.96
其他费用-2.00-0.12-0.22-0.01-0.31
结构变动度5.314.863.626.9615.85
), ArticleFig(id=1322607977023000581, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=CN, label=表6, caption=

2020—2024 年住院费用结构变动值和结构变动度（%）

, figureFileSmall=null, figureFileBig=null, tableContent=
项目DAMA
2020—20212021—20222022—20232023—20242020—2024
综合医疗服务费0.060.730.730.522.04
诊断费1.031.860.12-6.08-3.06
治疗费0.000.21-0.010.020.21
药费-0.34-4.20-0.96-1.50-7.00
其他费用-0.34-0.32-0.25-0.18-0.78
结构变动度1.787.332.078.3013.10
项目DC
2020—20212021—20222022—20232023—20242020—2024
综合医疗服务费0.070.430.381.282.15
诊断费0.880.16-1.31-1.75-2.03
治疗费0.360.35-0.402.082.39
药费-2.00-3.81-1.31-1.84-8.96
其他费用-2.00-0.12-0.22-0.01-0.31
结构变动度5.314.863.626.9615.85
), ArticleFig(id=1322607977119469574, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=EN, label=Table 7, caption=

Contribution rates (%) of individual cost components to structural changes in DAMA patients, 2020—2024

, figureFileSmall=null, figureFileBig=null, tableContent=
项目DAMA
2020—20212021—20222022—20232023—20242020—2024
综合医疗服务费3.519.9735.066.2415.57
诊断费58.1225.445.7473.2423.39
治疗费0.242.820.560.251.62
药费19.0757.3346.4318.0553.46
其他费用19.074.4312.202.215.96
项目DC
2020—20212021—20222022—20232023—20242020—2024
综合医疗服务费1.258.8110.5118.3513.58
诊断费16.503.2836.2625.2112.82
治疗费6.867.1910.9729.8615.10
药费37.6978.3436.2826.4356.54
其他费用37.692.375.990.151.96
), ArticleFig(id=1322607977211744263, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1322607971469743064, language=CN, label=表7, caption=

2020—2024 年DAMA患者各单项费用结构变动贡献率（%）

, figureFileSmall=null, figureFileBig=null, tableContent=
项目DAMA
2020—20212021—20222022—20232023—20242020—2024
综合医疗服务费3.519.9735.066.2415.57
诊断费58.1225.445.7473.2423.39
治疗费0.242.820.560.251.62
药费19.0757.3346.4318.0553.46
其他费用19.074.4312.202.215.96
项目DC
2020—20212021—20222022—20232023—20242020—2024
综合医疗服务费1.258.8110.5118.3513.58
诊断费16.503.2836.2625.2112.82
治疗费6.867.1910.9729.8615.10
药费37.6978.3436.2826.4356.54
其他费用37.692.375.990.151.96
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DRG模式下不同离院方式住院费用结构差异研究
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张洁 1, 2 , 杨春霞 1
现代预防医学 | 卫生政策与管理 2025,52(20): 3767-3773
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现代预防医学 |卫生政策与管理 2025 , 52 (20) : 3767 -3773
DRG模式下不同离院方式住院费用结构差异研究
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2.昆明市第一人民医院医务部（病案管理, bio={"content":"

张洁（1994—），女，硕士在读，统计师，研究方向：流行病学与卫生统计学

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张洁（1994—），女，硕士在读，统计师，研究方向：流行病学与卫生统计学

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张洁1, 2, 杨春霞1
作者信息
  • 1.四川大学华西公共卫生学院/华西第四医院流行病与卫生统计学系，四川　成都　610041
  • 2.昆明市第一人民医院医务部（病案管理
通讯作者:
杨春霞，E-mail:
作者简介:

张洁（1994—），女，硕士在读，统计师，研究方向：流行病学与卫生统计学

Cost structure comparison of DAMA and DC patients under the DRG model
Jie ZHANG1, 2, Chun-xia YANG1
Affiliations
  • Department of Epidemiology and Health Statistics, West China School of Public Health/west China Fourth Hospital, Sichuan University, Chengdu, Sichuan 610041, China
出版时间: 2025-10-25 doi: 10.20043/j.cnki.MPM.202506228
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摘要
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目的

在DRG支付模式下，分析非医嘱离院（DAMA）与医嘱离院（DC）患者住院费用构成及其变动特征，为优化资源配置和完善风险告知提供依据。

方法

选取某三甲医院2020—2024年全部DAMA与DC患者的病案首页数据，采用描述性统计与单因素分析比较两组费用差异，并应用聚类分析和结构变动度分析，探讨费用构成特征及其年度变动趋势。

结果

DAMA与DC患者在住院总费用及各项费用上差异均具统计学意义。DAMA患者呈现“多数低费用、少数高支出”的特征，以药品支出为主，治疗费用较低；DC患者费用分布更均衡，比例结构较合理。结构变动度分析显示, DC患者费用结构变动幅度高于DAMA，前者受治疗费和综合医疗服务费驱动，后者则主要受诊断费用波动影响。

结论

应重点优化DAMA患者费用结构，提升资源配置效率和控费水平，促进诊疗行为规范化，助力实现DRG改革目标。

DRG支付制度  /  非医嘱离院（DAMA）  /  医嘱离院（DC）  /  住院费用构成  /  结构变动度  /  聚类分析
Objective

To analyze the differences in inpatient cost structure and variation between patients discharged against medical advice (DAMA) and those discharged per medical advice (DC) under the DRG payment model, aiming to support resource optimization and risk communication strategies.

Methods

Front-page medical records of all DAMA and DC inpatients from a tertiary general hospital between 2020 and 2024 were collected. Descriptive statistics and univariate analysis were used to compare cost differences. Cluster analysis and structural variation degree analysis were conducted to examine cost composition and annual variation trends.

Results

Significant differences were found between the two groups in total and itemized inpatient costs. DAMA patients exhibited a “majority low-cost, minority high-expenditure” pattern, dominated by drug expenses and relatively low treatment costs. In contrast, DC patients showed more balanced cost distribution with stable proportions of diagnostic, treatment, and drug costs. Structural variation analysis indicated greater variation among DC patients, driven by changes in treatment and general medical service fees, while DAMA patients were mainly affected by diagnostic cost fluctuations.

Conclusion

Medical institutions should prioritize optimizing the cost structure of DAMA patients to enhance resource allocation and cost control, promoting standardized clinical practice and effective use of medical insurance funds under DRG reform.

DRG payment model  /  Discharge Against Medical Advice (DAMA)  /  Discharge per Medical Advice (DC)  /  Inpatient cost structure  /  Structural variation degree  /  Cluster analysis
张洁, 杨春霞. DRG模式下不同离院方式住院费用结构差异研究. 现代预防医学, 2025 , 52 (20) : 3767 -3773 . DOI: 10.20043/j.cnki.MPM.202506228
Jie ZHANG, Chun-xia YANG. Cost structure comparison of DAMA and DC patients under the DRG model[J]. Modern Preventive Medicine, 2025 , 52 (20) : 3767 -3773 . DOI: 10.20043/j.cnki.MPM.202506228
正文
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DAMA作为一种非常规医疗行为，常伴随医疗资源浪费、再入院率上升及医保基金使用效率低下等问题，对医疗体系的可持续性构成严峻挑战[1-4]。然而，目前国内外学界对DAMA患者的住院费用构成缺乏系统性研究，相关文献多集中于流行病学特征与患者行为动机，尚未形成基于定量数据的费用结构评估框架。随着按疾病诊断相关分组（Diagnosis-Related Groups, DRGs）付费制度在全国范围内加速实施，医疗机构面临医保支付约束，普遍采取控费措施以优化资源配置效率和成本结构，通过规范用药、压缩非必要支出、推进临床路径执行，使住院费用结构趋于合理[5-7]。但DAMA患者由于中断治疗、脱离标准路径，费用结构缺乏完整闭环，增加了控费难度，亦对精细化管理提出更高要求。本研究基于DAMA与DC患者2020—2024年住院数据，通过费用构成及结构变动度分析，填补该领域研究空白，为医疗机构优化DAMA患者资源配置、强化风险沟通机制提供数据支持，并为医保支付方建立差异化风险分担机制（如调整补偿系数）提供实证依据，从而助力DRGs政策目标的实现与健康公平的促进。
1　对象与方法
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1.1　研究对象
从某院病案信息系统中提取2020年1月1日至2024年12月31日出院病人共计400 027例，剔除离院方式为医嘱转院、死亡及其他情况的10 734例，最终纳入研究的DAMA患者为25 820例，DC患者为363 473例。
1.2　调查方法
从医院HIS系统提取2020—2024年所有DAMA及DC患者的病案首页数据，获取患者基本信息和费用信息。
1.3　统计分析方法
采用Excel 2016对原始数据进行整理，运用SPSS 25.0和R 4.3.2软件进行统计分析。由于住院费用不符合正态分布，采用M（IQR）对DAMA与DC患者各项费用进行描述性分析，并通过Mann-Whitney U检验比较两组间差异，检验水准α=0.05。进一步采用CLARA聚类分析及结构变动度法，探讨住院费用结构特征及2020—2024年间的年度变动趋势。
2　结果
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2.1　DAMA与DC患者的基本情况
本研究数据显示，样本医院DAMA患者的年龄中位数为58（36，72）岁，住院天数中位数为5（3，9）天。根据DRG主要诊断章节分类，在26个诊断章节中，呼吸系统疾病（23.65%）、循环系统疾病（14.67%）和消化系统疾病（12.31%）构成比位列前三。相比之下，DC患者的年龄中位数为57（37，71）岁，住院天数中位数为7（5，10）天，其疾病构成以循环系统疾病（17.46%）、呼吸系统疾病（16.85%）和消化系统疾病（10.95%）为主。
2.2　DAMA与DC患者住院费用描述性分析及住院费用差异性分析
DAMA组在住院总费用、自付费用及各项费用构成上均低于DC组，差异具有统计学意义（P<0.01）。DAMA组在综合医疗服务费、诊断费、药费等整体偏低，反映其总体医疗资源利用水平偏低。进一步分析显示，DAMA组的实际住院天数短于DC组，且四分位数间距明显大于DC组，两组间差异同样具有统计学意义（P<0.01）。这一结果提示DAMA患者可能存在诊疗过程未完整完成的情况，体现出其住院路径的不规范性和住院天数的高度离散特征，见表1。
2.3　DAMA与DC患者住院费用聚类分析
采用CLARA聚类法对DAMA与DC患者的住院费用数据进行聚类分析，并按照住院总费用将患者划分为5类（Cluster 1 至 Cluster 5）。结合聚类图与堆叠图结果，药品费用与诊断费用是区分各类患者的主要变量。通过对不同聚类中患者数量分布、费用水平与费用构成的综合分析发现，DAMA患者中低费用组（Cluster 1）占比最高，达27.52%，人均费用仅为1 882.35元；而高费用组（Cluster 5）仅占2.32%，但人均费用高达16.7万元，呈现出“多数低费用、少数极高支出”的不均衡结构，提示可能存在治疗中断或医疗服务不足的情况。相比之下，DC患者在各聚类中的分布相对均衡，高费用组人均费用仅为4.3万元，整体费用波动较小。从费用构成来看，DAMA患者低费用组以诊断费用为主，高费用组则呈现“药品主导型”特征，其中药品费用占比超过40%，反映出资源配置前移的趋势。相较而言，DC患者的费用结构更为均衡，诊断、治疗及药品费用占比较为合理，体现出诊疗路径的规范性与完整性，见表2～3和图1。
对DAMA患者中cluster1和cluster5中前五DRGs组进行分析，cluster1以轻症疾病为主，平均住院天数为2.27～4.66天，平均住院费用为1 409～2 371元，DRGs权重较低（0.225 1～0.426 1），说明此类DAMA患者可能多因症状缓解或费用考量提前离院。而cluster5则以重症病例为主，涵盖有创呼吸机支持、介入手术及复杂器械植入等高资源疾病，DRGs权重高（2.874 6～11.436 2），平均住院费用达13万～17万元，日均费用最高超过1万元，反映其在治疗强度和经济负担方面的高度集中，见表4～5。
2.4　DAMA与DC患者住院费用结构变动度分析
2020—2024年间，DAMA与DC患者在住院费用结构变动度及其变动来源方面存在显著差异。DC患者累计结构变动度为15.85%，高于DAMA患者的13.10%，说明医嘱离院患者费用结构变动幅度更大。2023—2024年度，DC患者结构变动度达6.96%，主要由治疗费（+2.08%）和综合医疗服务费（+1.28%）占比上升推动。同期，DAMA患者结构变动度为8.30%，主要受诊断费用占比大幅下降（-6.08%）影响，导致整体结构波动加剧。从费用类别来看，综合医疗服务费和治疗费普遍呈正向变动，诊断费、药费及其他费用则呈负向变动，其中药费变化最为剧烈，是主要变动来源，见表6。结果表明，不同离院方式对应的费用结构调整路径与主导因素不同，医疗机构应根据患者离院类型差异化管理资源配置与费用结构，以提升控费效能和服务质量。
从结构变动贡献率看，药品费用是DAMA与DC两组患者中最主要的变动来源。在DC患者中，药费贡献率达56.54%，反映出药品改革和控费政策的深远影响；DAMA患者药费贡献率亦达53.46%。值得关注的是，诊断费用在DAMA患者中于2023—2024年对结构变动的贡献率高达73.24%，2020—2021年也达58.12%，可能与其诊疗中断或检查提前集中的行为特征相关。综合医疗服务费在两组中均呈增长趋势，DAMA患者中对总变动的贡献为15.57%，DC患者为13.58%，表明该类费用在住院结构中占比持续提升，或与服务价格调整和技术服务价值重估密切相关，见表7。
3　讨论
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3.1　DRGs付费政策实施后，住院费用呈下降趋势
自2021年DRGs（疾病诊断相关分组）付费政策正式实施以来，该院住院费用及自付费用总体持续降低，药品费用与诊断费用的减少尤为明显。这一变化在一定程度上体现出DRGs按病种分组定额付费机制对医院成本控制行为的制度激励效应。通过设定相对固定的疾病支付标准，DRGs政策有效约束了医院的非理性医疗行为，促使医疗机构在诊疗路径设计、资源配置及流程优化等方面加强管理与控制，从而提高了服务效率，降低了医疗过程中的不必要支出，也在一定程度上避免了患者承担非必要诊疗项目的额外费用，间接减轻了其经济负担。
3.2　DAMA患者住院费用水平整体偏低，且费用分布呈现出高度离散、结构不均衡的特征，常伴随高诊断费及药费
DAMA群体内部既包含部分病情较轻、在接受初步诊疗后自行离院的患者，也涵盖未完成治疗流程的重症患者，使得四分位数间距（IQR）显著扩大，反映出费用波动幅度较大。值得关注的是，该类患者在住院早期常伴随较高的诊断费用与药品费用，提示在DRGs付费制度和医保控费政策的约束下，医疗机构普遍将资源配置前移，以保障关键性检查与基础治疗在付费节点之前完成，规避后续治疗阶段可能面临的支付限制。该策略在DAMA患者中尤为明显，亦反映出医院在面对不确定出院行为时的资源调度逻辑。此外，部分临床科室在绩效考核机制中虽已受到“药占比”等政策指标的约束，可能在无形中驱动诊断与药品费用的前置化，形成早期费用堆积，从而干扰了原有费用结构的合理性与均衡性[8]。为应对这一问题，医疗机构亟需优化院内过程管理机制，提升费用结构的科学性与可控性，从而在保障患者权益的同时，实现住院费用的有效监管与资源的合理配置。
3.3　DAMA与DC患者在住院费用结构变动方面存在显著差异，主要体现于就医行为、政策响应和支付机制适配性的不同
首先，就医行为差异是关键因素。DC患者通常完成了较为规范的诊疗流程，费用结构相对稳定，治疗费和综合医疗服务费占比上升。相较之下，DAMA患者因中途离院或治疗中断，诊断费波动显著，费用结构呈现不连续性，结构变动度在个别年度明显升高。其次，药品控费政策的推进是共同影响因素。国家集中带量采购、医保目录动态调整等措施显著压缩药品费用[9-11]，使其成为结构变动的主要来源之一，DC患者受影响尤为显著。第三，医疗服务价格的调整与结构升级亦发挥了重要作用。政策导向强调“以技养医”[12]，提高医护服务价格比重，推动综合医疗服务费持续增长，体现出服务价值在费用结构中的提升。最后，医保支付方式改革产生了分化效应。DC患者更符合DRGs支付体系，费用结构受制度性规范引导；而非医嘱离院患者由于诊疗不完整，表现出更强的年度异质性和结构不确定性。
3.4　强化控费与路径管理，分类干预DAMA群体
为有效降低DAMA发生率，提升住院费用结构合理性，医疗机构应在现有规范管理的基础上，将控费重心适度向DAMA患者群体倾斜，构建以规范诊疗与精细控费为导向的综合干预机制。一方面，应健全出院管理制度，建立DAMA风险预警体系，推广医患共同决策（Shared Decision Making, SDM）模式[13-14]，结合信息系统实时识别提前离院倾向患者，及时开展沟通与健康教育，提升患者依从性，减少因信息不对称导致的中途退院。另一方面，在保持DC患者费用结构稳定性的基础上，应将成本控制理念全面融入临床实践，依托DRGs支付机制，推进多段临床路径管理[15]，引导医师合理用药、规范检查，避免前期资源投入失衡与医疗浪费。同时，应将路径执行率、患者依从率等指标纳入绩效考核，激励医务人员在确保治疗效果的同时提升管理效能与成本控制能力。通过上述措施实现DAMA行为的有效控制，降低由其引发的医疗风险与医保支出，进一步保障医疗服务的连续性与结构优化，推动医院管理体系向规范化与精细化转型。
3.5　本研究的局限性与展望
首先，研究对象仅限于昆明市某三甲医院，患者在疾病严重程度、经济状况及就医行为等方面与基层医疗机构存在差异，可能导致选择性偏倚，限制了研究结论的外推性。其次，结构变动度分析虽可反映费用构成的年度变化趋势，但作为静态指标，其解释力有限。尽管本文结合相关政策进行了初步解析，仍可能难以全面揭示背后的驱动机制。未来研究可从以下方面予以优化：其一，纳入不同地域与不同级别医疗机构的代表性样本，开展多中心研究；其二，结合临床路径执行情况与医保政策调整背景，深化对结构变动成因的理解，实现从静态描述向机制建模的转变，增强研究的政策指导价值与实践适用性。未来研究可对DAMA群体进行进一步细分，识别轻症主动离院与重症中断治疗等不同亚群体，深入分析其住院费用构成、资源消耗特征及影响因素，为制定差异化管理策略提供数据支持与决策依据。

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2025年第52卷第20期
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doi: 10.20043/j.cnki.MPM.202506228
  • 接收时间：2025-06-13
  • 首发时间：2026-10-29
  • 出版时间：2025-10-25
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    1.四川大学华西公共卫生学院/华西第四医院流行病与卫生统计学系，四川　成都　610041
    2.昆明市第一人民医院医务部（病案管理

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2种不同金属材料的力学参数
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小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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