BMC Health Serv Res. 2026 Jun 6. doi: 10.1186/s12913-026-14908-1. Online ahead of print.
ABSTRACT
BACKGROUND: Diagnosis-related groups (DRGs) are a key instrument in health insurance payment reform. However, for DRG groups with substantial heterogeneity in disease severity and surgical complexity, uniform payment standards may lead to a mismatch between reimbursement and actual costs. The ureteral surgery group (LC19) under the China Healthcare Security Diagnosis-Related Groups (CHS-DRG) system shows marked variation in resource utilization and is therefore at high risk of systematic financial loss. This study aimed to identify factors influencing hospitalization costs in the LC19 group from a DRG profit-loss perspective, providing evidence to support the optimization of payment mechanisms.
METHODS: A retrospective cross-sectional study was conducted using data from two tertiary general hospitals in Hunan Province, China. A total of 2,568 inpatient cases classified under the CHS-DRG LC19 group between July 2023 and December 2024 were included. Total hospitalization cost was set as the dependent variable. Independent variables covered patient demographics, disease and treatment characteristics, surgical characteristics, and inpatient management factors. Univariate analyses and multivariate linear regression were performed, followed by comparisons of DRG profit-loss status and cost structures across key influencing factors.
RESULTS: Multivariate linear regression analysis showed that pyonephrosis (βt = 0.31), length of stay ≥ 7 days (βt = 0.22), and level IV surgery (βt = 0.21) were major factors associated with increased hospitalization costs, whereas day surgery was significantly associated with lower costs (βt = – 0.09). DRG profit-loss analysis indicated that cases involving procedure code 56.41, level IV surgery, or length of stay ≥ 7 days had deficit rates exceeding 80%. Cost structure analysis revealed that level IV surgery was associated with significantly higher expenditures across all cost components, while day surgery demonstrated clear advantages in laboratory test and diagnostic examination costs.
CONCLUSIONS: Hospitalization costs and DRG financial performance in the LC19 group are mainly driven by disease severity, surgical complexity, and inpatient management patterns. Refining grouping criteria, establishing dynamic stratified payment standards, and expanding day surgery pathways may improve payment accuracy and healthcare efficiency.
PMID:42251371 | DOI:10.1186/s12913-026-14908-1
