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§” ”§—≠: °≈ÿà¡«‘π‘®©—¬‚√§√à«¡, «—ππÕπ, °≈ÿà¡μ°‡°≥±å

Abstract Trimming Method for Outlier Trim Point of Casemix Nilawan Upakdee*

*Faculty of Pharmaceutical Sciences, Naresuan University

This paper aims to review and describe method to determine outlier trim point for outlier cases in diagnosis related group. This review demonstrates concept and experiences in each country. The outliers cases divided into 2 categories: length of stay (LOS) outlier and cost outlier. Outlier trim point methods for LOS were 4 methods: inter-quartile range (IQR) method, 10^th - 95^th percentile method, L3H3 method and geometric mean method. The literature review will be information for decision in formula of outlier trim point in Thailand. Since the trimming of outlier cases will effect for relative weights that used for payment to hospitals.

Keywords: diagnosis related group, length of stay, outlier

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μà“ß°—π ·≈–‚√§∑’Ëæ∫‰¥â‰¡à∫àÕ¬⁽⁴⁾ „π°“√§”π«≥§à“¡“μ√∞“π

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·≈–®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å (high trim point: HTP)⁽⁵⁾

«‘∏’°“√·∑π§à“¢âÕ¡Ÿ≈μâπ∑ÿπ∑’ËπâÕ¬°«à“À√◊Õ¡“°°«à“®ÿ¥μ—¥«—π πÕπ —ÈπÀ√◊Õπ“π‡°‘π‡°≥±å‡√’¬°«à“ truncation

§à“«—ππÕπ‡©≈’ˬ (length of stay: LOS)

§à“‡©≈’ˬ«—ππÕπ (average length of stay: ALOS) À“

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√à«¡®–¡’°“√§”π«≥À“§à“¡“μ√∞“π«—ππÕπ‡©≈’ˬ (average length of stay: ALOS) ‚¥¬§”π«≥®“°§à“‡©≈’ˬ‡≈¢§≥‘μ

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«‘∏’§‘¥®ÿ¥μ—¥«—ππÕπ —Èπ·≈–«—ππÕππ“π‡°‘π‡°≥±å

1. «‘∏’æ‘ —¬§«Õ‰∑≈å (The inter-quartile range method À√◊Õ IQR method)

«‘∏’§‘¥®ÿ¥μ—¥«—ππÕπ —Èπ·≈–π“π‡°‘π‡°≥±å¥â«¬ ∂‘μ‘·∫∫

πÕπ-æ“√“‡¡μ√‘° ‚¥¬„™â§«Õ‰∑≈å∑’Ë 1 (Q1) À√◊Õ‡ªÕ√凴Áπ‰∑≈å∑’Ë 25 ·≈–§«Õ‰∑≈å∑’Ë 3 (Q3) À√◊Õ‡ªÕ√凴Áπ‰∑≈å∑’Ë 75 æ∫«à“«‘∏’π’È

¡’°“√„™â„πª√–‡∑»Õ—ß°ƒ… Õ‘μ“≈’ ‡¥π¡“√å°^(9,10) ·≈–ª√–‡∑»

ÕÕ ‡μ√‡≈’¬ ‚¥¬ Australian Department of Health and Family Services⁽¹¹⁾ ¥—ßπ’È

®ÿ¥μ—¥«—ππÕπ —Èπ°«à“‡°≥±å = Q1 - k × (Q3 - Q1)

®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å = Q3 + k × (Q3 - Q1)

‚¥¬ k ‡ªìπ§à“§ß∑’Ë ‡™àπ 1.5, 2, 2.5 μ—«Õ¬à“߇™àπ ª√–‡∑»

‡∫≈‡¬’¬¡„™â‡°≥±å®ÿ¥μ—¥«—ππÕπ —Èπ°«à“‡°≥±å‡ªÕ√凴Áπ‰∑≈å∑’Ë 25 - 1.5 × IQR ·≈–®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å ‡ªÕ√凴Áπ‰∑≈å∑’Ë 75 + 1.5 × IQR⁽¹²⁾ ª√–‡∑» ‡ªπ„™â‡°≥±å®ÿ¥μ—¥«—ππÕππ“π

‡°‘π‡°≥±å‡ªÕ√凴Áπ‰∑≈å∑’Ë 75 + 1.5 × IQR À√◊Õ ‡ªÕ√凴Áπ‰∑≈å

∑’Ë 75 + 2.0 × IQR⁽¹³⁾

°“√„™â«‘∏’æ‘ —¬§«Õ‰∑≈å‡À¡“– ”À√—∫¢âÕ¡Ÿ≈∑’Ë¡’°“√°√–®“¬

·∫∫ª°μ‘ À“°¢âÕ¡Ÿ≈¡’°“√°√–®“¬μ—«·∫∫‡∫âÀ√◊Õ¡’°“√

°√–®“¬μ—«¡“°®–∑”„Àâ§à“®ÿ¥μ—¥«—ππÕπ∑’ˉ¥â¡’Õ”π“®°“√

∑”𓬧à“√—°…“欓∫“≈μË”⁽¹⁰⁾ ·≈–«‘∏’æ‘ —¬§«Õ‰∑≈åπ’Ȭ—ß„™âμ—¥

μâπ∑ÿπ∑’ËμË”°«à“‡°≥±å‰¥â

2. «‘∏’‡ªÕ√凴Áπ‰∑≈å∑’Ë 10 ·≈– 95 (The 10^th - 95^th per- centile method)⁽¹⁴⁾

°“√„™â‡ªÕ√凴Áπ‰∑≈å∑’Ë 10  ”À√—∫®ÿ¥μ—¥«—ππÕπ —Èπ°«à“

‡°≥±å ·≈– ·≈–‡ªÕ√凴Áπ‰∑≈å∑’Ë 95  ”À√—∫®ÿ¥μ—¥«—ππÕππ“π

‡°‘π‡°≥±å ·≈–«‘∏’‡ªÕ√凴Áπ‰∑≈åπ’ÈÕ“®„™â°—∫°√≥’μâπ∑ÿπμË”°«à“

‡°≥±å‰¥â ‡™à𠇪Õ√凴Áπ‰∑≈å∑’Ë 5 3. «‘∏’ L3H3 (L3H3 method)

«‘∏’π’ȇªìπ°“√§‘¥®ÿ¥μ—¥«—ππÕπ —Èπ·≈–π“π‡°‘π‡°≥±å¥â«¬

 ∂‘μ‘·∫∫πÕπ-æ“√“‡¡μ√‘° ¡’°“√„™â„πª√–‡∑»®’π ·≈–√—∞

𑫇´“∑凫≈ å ª√–‡∑»ÕÕ ‡μ√‡≈’¬⁽¹⁵⁾ ¥—ßπ’È

®ÿ¥μ—¥«—ππÕπ —Èπ‡°‘π‡°≥±å = 1/3 ¢Õß«—ππÕπ‡©≈’ˬ

®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å = 3 ‡∑à“¢Õß«—ππÕπ‡©≈’ˬ

„π∫“ß√—∞¢Õߪ√–‡∑»ÕÕ ‡μ√‡≈’¬ ‡™àπ √—∞§«’π å·≈π¥å „™â

®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å∑’Ë 5 ‡∑à“¢Õß«—ππÕπ‡©≈’ˬ ·≈–

ÕÕ ‡μ√‡≈’¬„μâ „™â®ÿ¥μ—¥«—ππÕπ —Èπ‡°‘π‡°≥±å∑’Ë 3 ‡∑à“¢Õß  à«π‡∫’ˬ߇∫π¡“μ√∞“π (‡¡◊ËÕ§à“«—ππÕπ‡©≈’ˬ¡“°°«à“ 4 «—π) À√◊Õ®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±åÕ“®‡ªìπ§à“Õ◊Ë𠇙àπ APDRG Suisse ‡«Õ√å™—Ëπ 4.1 „™â Ÿμ√ L3H2.4⁽¹⁶⁾

4. «‘∏’§à“‡©≈’ˬ‡√¢“§≥‘μ (Geometric mean method)⁽¹⁷⁾

«‘∏’π’ȇªìπ°“√„™â ∂‘μ‘·∫∫æ“√“‡¡μ√‘°¥â«¬§à“‡©≈’ˬ

‡√¢“§≥‘μ (geometric mean: GM) ¢Õß«—ππÕπ √à«¡°—∫§à“

 à«π‡∫’ˬ߇∫π¡“μ√∞“π (standard deviation: SD) ®–∑”„Àâ

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¡’°“√„™â„πª√–‡∑»¬ÿ‚√ª ‡™à𠇬Õ√¡π’  ‡ªπ ·≈– À√—∞Õ‡¡√‘°“

‚¥¬°“√À“§à“®ÿ¥μ—¥«—ππÕπ®“° Ÿμ√ geometric mean ± a SD ‚¥¬ a ‡ªìπ§à“§ß∑’Ë ‡™àπ 2 À√◊Õ 3 ¥—ßπ’È

 Ÿμ√ GM2: ®ÿ¥μ—¥«—ππÕπ = Geometric mean ± 2 SD  Ÿμ√ GM3: ®ÿ¥μ—¥«—ππÕπ = Geometric mean ± 3 SD μ—«Õ¬à“ß HCFA °”Àπ¥®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å®“°

 Ÿμ√π’È §◊Õ Geometric mean + 1.94 SD À√◊Õ 20 «—π ®–

‡ªìπ°≈ÿࡺŸâªÉ«¬∑’Ë¡’«—ππÕππ“π‡°‘π‡°≥±å⁽¹⁸⁾ πÕ°®“°π’È «‘∏’§à“

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ª°μ‘Õ’°¥â«¬⁽¹⁹⁾

ß“π«‘®—¬μà“ßÊ ∑’ˇ°’ˬ«¢âÕß

Gong Z ·≈–§≥– ‡°Á∫¢âÕ¡Ÿ≈®“°‡«™√–‡∫’¬πºŸâªÉ«¬„π

¢Õß‚√ß欓∫“≈ 3 ·Ààß„πª√–‡∑»®’π√–À«à“ߪï§.».1998-2001

«‘‡§√“–Àå¢âÕ¡Ÿ≈«—ππÕπ·≈–§à“√—°…“欓∫“≈®”π«π 161,478

‡«™√–‡∫’¬π ·≈– 84,028 ‡«™√–‡∫’¬π μ“¡≈”¥—∫ ®—¥°≈ÿࡥ⫬

‚ª√·°√¡°≈ÿà¡«‘π‘®©—¬‚√§√à«¡ª√–‡∑»ÕÕ ‡μ√‡≈’¬ (Australian refined-diagnosis related groups: AR-DRGs) ‡«Õ√å™—Ëπ 4.0 ·≈–À“§à“Õ”π“®°“√∑”𓬠(reduction in variance: R²)

´÷Ëß„™âÕ∏‘∫“¬«à“μ—«·ª√Õ‘ √– “¡“√∂∑”π“¬μ—«·ª√μ“¡‰¥â¡“°

πâÕ¬‡æ’¬ß„¥ ·≈–§à“ —¡ª√– ‘∑∏‘ϧ«“¡·ª√ª√«π (coefficient of variation: CV) ‡æ◊ËÕæ‘®“√≥“§«“¡§≈⓬§≈÷ß°—π„π·μà≈–

°≈ÿà¡«‘π‘®©—¬‚√§√à«¡ ´÷Ëß§à“ —¡ª√– ‘∑∏‘ϧ«“¡·ª√ª√«π®–

∫Õ°∂÷ߧ«“¡·ª√ª√«π¢Õß°≈ÿà¡μ—«Õ¬à“ß«à“¡’¡“°À√◊ÕπâÕ¬ ∂â“

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‡¡◊ËÕ∑”°“√‡ª√’¬∫‡∑’¬∫√–À«à“ß«‘∏’ L3H3 ·≈–«‘∏’æ‘ —¬

§«Õ‰∑≈å„π°“√À“®ÿ¥μ—¥ºŸâªÉ«¬μ°‡°≥±å∑—Èß«—ππÕπ·≈–§à“

√—°…“欓∫“≈ æ∫«à“ °“√„™â‡°≥±å®ÿ¥μ—¥ºŸâªÉ«¬μ°‡°≥±å∑—Èß 2

«‘∏’ ∑”„Àâ§à“Õ”π“®°“√∑”𓬇æ‘Ë¡¢÷Èπ  ”À√—∫§à“ —¡ª√– ‘∑∏‘Ï

§«“¡·ª√ª√«π ‡¡◊ËÕ„™â«‘∏’μ—¥¢âÕ¡Ÿ≈ºŸâªÉ«¬¥â«¬‡°≥±å®ÿ¥μ—¥«—π πÕπ·≈â« ∑”„Àâ¡’®”π«π°≈ÿà¡«‘π‘®©—¬‚√§√à«¡∑’Ë¡’§à“ —¡ª√– ‘∑∏‘Ï

§«“¡·ª√ª√«π¡“°°«à“√âÕ¬≈– 100.0 ≈¥≈ß ∑—Èß«—ππÕπ·≈–

§à“√—°…“欓∫“≈ · ¥ß«à“°“√„™â‡°≥±å®ÿ¥μ—¥«—ππÕπºŸâªÉ«¬

μ°‡°≥±å∑”„À⧫“¡·ª√ª√«π¿“¬„π°≈ÿà¡«‘π‘®©—¬‚√§√à«¡≈¥≈ß (μ“√“ß∑’Ë 1)

Shahram Ghaffari ·≈–§≥– «‘‡§√“–Àå¢âÕ¡Ÿ≈®“°∞“π

¢âÕ¡Ÿ≈°“√πÕπ‚√ß欓∫“≈¢ÕßÕߧå°√ª√–°—π ÿ¢¿“æª√–‡∑»

Õ‘À√à“π√–À«à“ߪï§.». 2003-2004 ®”π«π 445,324 §π ®—¥°≈ÿà¡

«‘π‘®©—¬‚√§√à«¡‚¥¬‚ª√·°√¡°≈ÿà¡«‘π‘®©—¬‚√§√à«¡ª√–‡∑»

ÕÕ ‡μ√‡≈’¬ (AR-DRGs) „π°“√À“®ÿ¥μ—¥ºŸâªÉ«¬μ°‡°≥±å

¥â«¬«‘∏’ L3H3 «‘∏’æ‘ —¬§«Õ‰∑≈å·≈–«‘∏’‡ªÕ√凴Áπ‰∑≈å∑’Ë 10 ·≈–

95 æ∫«à“ ®”π«π¢âÕ¡Ÿ≈μ°‡°≥±å‡¡◊ËÕ„™â«‘∏’ IQR ®–¡’¡“°‡ªìπ  Õ߇∑à“‡¡◊ËÕ‡∑’¬∫°—∫„™â«‘∏’ L3H3 ·≈–«‘∏’‡ªÕ√凴Áπ‰∑≈å∑’Ë 10 ·≈–

95 ‚¥¬®”π«π°≈ÿà¡«‘π‘®©—¬‚√§√à«¡∑’Ë¡’§à“ —¡ª√– ‘∑∏‘ϧ«“¡

·ª√ª√«ππâÕ¬°«à“√âÕ¬≈– 100.0 ‡æ‘Ë¡¢÷Èπ®“°√âÕ¬≈– 77.0 „π

°≈ÿà¡∑’ˉ¡à‰¥âμ—¥¢âÕ¡Ÿ≈ºŸâªÉ«¬μ°‡°≥±å«—ππÕπÕÕ° (untrimmed)

‡ªìπ√âÕ¬≈– 96.0, 99.0 ·≈– 100.0 ‡¡◊ËÕ„™â‡°≥±å®ÿ¥μ—¥ºŸâªÉ«¬

μ°‡°≥±å¥â«¬«‘∏’‡ªÕ√凴Áπ‰∑≈å∑’Ë 10 ·≈– 95 «‘∏’æ‘ —¬§«Õ‰∑≈å

·≈–«‘∏’ L3H3 μ“¡≈”¥—∫ · ¥ß«à“°“√„™â‡°≥±å®ÿ¥μ—¥ºŸâªÉ«¬

μ°‡°≥±åπ’È∑”„Àâ¢âÕ¡Ÿ≈¡’§«“¡§≈⓬§≈÷ß°—π¡“°¢÷Èπ ‚¥¬«‘∏’

L3H3 ¡’®”π«π°≈ÿà¡«‘π‘®©—¬‚√§√à«¡∑’Ë¡’§à“ —¡ª√– ‘∑∏‘ϧ«“¡

·ª√ª√«ππâÕ¬°«à“√âÕ¬≈– 100.0 ¡“°∑’Ë ÿ¥ ¥—ßπ—Èπ«‘∏’ L3H3

®÷߇ªìπ«‘∏’∑’ˇÀ¡“– ¡ ‡π◊ËÕß®“° “¡“√∂≈¥§«“¡·ª√ª√«π¢Õß

¢âÕ¡Ÿ≈‰¥â¡“°∑’Ë ÿ¥⁽¹⁴⁾ (μ“√“ß∑’Ë 2)

 ”À√—∫§à“Õ”π“®°“√∑”𓬠æ∫«à“ °≈ÿà¡∑’ˉ¡à‰¥âμ—¥

¢âÕ¡Ÿ≈ºŸâªÉ«¬μ°‡°≥±å«—ππÕπÕÕ° (untrimmed) ¡’§à“ 0.17

‡¡◊ËÕ∑”°“√μ—¥¢âÕ¡Ÿ≈¥â«¬«‘∏’ L3H3 «‘∏’æ‘ —¬§«Õ‰∑≈å·≈–«‘∏’

‡ªÕ√凴Áπ‰∑≈å∑’Ë 10 ·≈– 95 ¡’§à“Õ”π“®°“√∑”𓬇ªìπ 0.53, 0.48 ·≈– 0.51 μ“¡≈”¥—∫ · ¥ß«à“«‘∏’ L3H3 ∑”„ÀâÕ”π“®

°“√∑”𓬧à“√—°…“欓∫“≈¡“°∑’Ë ÿ¥ √Õß≈ß¡“§◊Õ«‘∏’‡ªÕ√å

‡´Áπ‰∑≈å∑’Ë 10 ·≈– 95 «‘∏’æ‘ —¬§«Õ‰∑≈å·≈–«‘∏’∑’ˉ¡à‰¥âμ—¥

¢âÕ¡Ÿ≈ºŸâªÉ«¬μ°‡°≥±å«—ππÕπÕÕ° (untrimmed) μ“¡≈”¥—∫

Francesc Cots ·≈–§≥– À“«‘∏’°”Àπ¥®ÿ¥μ—¥ºŸâªÉ«¬

μ°‡°≥±å∑’ˇÀ¡“– ¡ ´÷ËßμâÕ߇ªìπ«‘∏’∑’Ë· ¥ß§«“¡ —¡æ—π∏å

√–À«à“ß«—ππÕπ°—∫§à“„™â®à“¬‰¥â¥’ ·À≈àߢâÕ¡Ÿ≈®“°‡«™√–‡∫’¬π ºŸâªÉ«¬®”π«π 35,262 ‡«™√–‡∫’¬π ®“°‚√ß欓∫“≈√—∞ 2 ·Ààß

„π‡¡◊Õß∫“√凴‚≈π“ √–À«à“ßªï §.». 1995-1996 ‰¥â√—∫°“√

«‘‡§√“–ÀåÀ“®ÿ¥μ—¥ºŸâªÉ«¬μ°‡°≥±å‚¥¬‡ª√’¬∫‡∑’¬∫√–À«à“ß«‘∏’

μ“√“ß∑’Ë 1 ‡ª√’¬∫‡∑’¬∫º≈∑’ˉ¥â®“°«‘∏’§‘¥®ÿ¥μ—¥«—ππÕπ∑’Ë·μ°μà“ß°—π

Untrimmed IQR L3H3

«—ππÕπ (length of stay)

§à“Õ”π“®°“√∑”𓬠(R2) 0.12 0.34 0.45

®”π«π°≈ÿà¡∑’Ë¡’§à“ —¡ª√– ‘∑∏‘ϧ«“¡·ª√ª√«π‡°‘π 100% 192 27 0

√âÕ¬≈–¢Õß®”π«π°≈ÿࡇ∑’¬∫°—∫®”π«π¢âÕ¡Ÿ≈∑—ÈßÀ¡¥ 39.9 0.4 0.0

μâπ∑ÿπ (cost)

§à“Õ”π“®°“√∑”𓬠(R2) 0.17 0.45 0.59

®”π«π°≈ÿà¡∑’Ë¡’§à“ —¡ª√– ‘∑∏‘ϧ«“¡·ª√ª√«π‡°‘π 100% 196 38 1

√âÕ¬≈–¢Õß®”π«π°≈ÿࡇ∑’¬∫°—∫®”π«π¢âÕ¡Ÿ≈∑—ÈßÀ¡¥ 53.2 0.9 0.0

μ“√“ß∑’Ë 2 ®”π«π°≈ÿà¡«‘π‘®©—¬‚√§√à«¡∑’Ë¡’§à“ —¡ª√– ‘∑∏‘ϧ«“¡·ª√ª√«ππâÕ¬°«à“√âÕ¬≈– 100.0 ·μà≈–«‘∏’

Trimmed Untrimmed

L3H3 IQR ‡ªÕ√凴Áπ‰∑≈å∑’Ë 10 ·≈– 95

®”π«π°≈ÿà¡«‘π‘®©—¬‚√§√à«¡ 546 540 546 545

√âÕ¬≈–°≈ÿà¡«‘π‘®©—¬‚√§√à«¡∑—ÈßÀ¡¥ 77.0% 100.0% 99.0% 96.0%

√âÕ¬≈–¢ÕߢâÕ¡Ÿ≈∑—ÈßÀ¡¥ 58.0% 100.0% 99.9% 99.8%

æ‘ —¬§«Õ‰∑≈å §‘¥®“°‡ªÕ√凴Áπ‰∑≈å∑’Ë 75 + a IQR ‚¥¬ a ‡ªìπ

§à“§ß∑’Ë ‡™àπ 1.5 À√◊Õ 2 ·≈–«‘∏’§à“‡©≈’ˬ‡√¢“§≥‘μ (geometric mean) ®“° Ÿμ√ geometric mean ± a SD ‚¥¬ a ‡ªìπ§à“

§ß∑’Ë ‡™àπ 2 À√◊Õ 3 æ∫«à“«‘∏’§à“‡©≈’ˬ‡√¢“§≥‘μ ± 2 ‡∑à“¢Õß  à«π‡∫’ˬ߇∫π¡“μ√∞“π (GM2) ‡ªìπ«‘∏’∑’ˇÀ¡“– ¡∑’Ë ÿ¥

 “¡“√∂· ¥ß§«“¡ —¡æ—π∏å√–À«à“ߧà“√—°…“欓∫“≈·≈–«—π πÕπ‰¥â¥’°«à“«‘∏’Õ◊Ëπ·≈–¡’§à“§«“¡‰« (sensitivity) ¡“°°«à“«‘∏’

Õ◊Ëπ ¢≥–∑’Ë GM3 ¡’§à“§«“¡®”‡æ“– (specificity) ¡“°∑’Ë ÿ¥⁽²¹⁾ Pirson M ·≈–§≥– À“ªí®®—¬∑’ËÕ∏‘∫“¬°“√„™â∑√—欓°√

„π°≈ÿà¡μ°‡°≥±å¥â«¬°“√«‘‡§√“–Àå∂¥∂Õ¬‚≈®‘ μ‘°·≈–«‘∏’

μâπ‰¡â°“√μ—¥ ‘π„® (decision tree approach) ‡æ◊ËÕ∑¥ Õ∫

ªí®®—¬∑”𓬰≈ÿà¡μ°‡°≥±å°“√„™â∑√—欓°√ (cost outlier)

¡“®“°«‘∏’‡ªÕ√凴Áπ‰∑≈å∑’Ë 75 + 1.5 IQR ·≈–°≈ÿà¡μ°‡°≥±å

°“√„™â∑√—欓°√πâÕ¬®“°«‘∏’‡ªÕ√凴Áπ‰∑≈å∑’Ë 25 - 1.5 IQR æ∫«à“

§«“¡πà“®–‡ªìπ„π°“√∑’˺ŸâªÉ«¬„™â∑√—欓°√¡“°π—Èπ ‡π◊ËÕß®“°

°“√¡’®”π«π«—ππÕπ∑’ˇæ‘Ë¡¢÷Èπ (Odd Ratio = 1.08) °“√

√—°…“„πÀÕºŸâªÉ«¬Àπ—° (Odd Ratio = 1.46) ·≈–°“√¡’ªí®®—¬

∑“ß —ߧ¡ (Odd Ratio = 1.44)  à«π§«“¡πà“®–‡ªìπ„π°“√∑’Ë ºŸâªÉ«¬„™â∑√—欓°√πâÕ¬ ‡π◊ËÕß®“°°“√‡ªìπºŸâªÉ«¬ ŸßÕ“¬ÿ (Odd Ratio = 0.98)⁽²²⁾

«‘®“√≥å

°“√À“®ÿ¥μ—¥«—ππÕπ∑—Èß„πª√–‡∑»‰∑¬·≈–μà“ߪ√–‡∑»

®“°ß“π«‘®—¬μà“ßÊ ®–‡ÀÁπ‰¥â«à“°“√À“®ÿ¥μ—¥ºŸâªÉ«¬μ°

‡°≥±å¡’À≈“¬«‘∏’ ·μà≈–«‘∏’¡’¢âÕ¥’·≈–¢âÕ‡ ’¬μà“ß°—π ∫“ß ª√–‡∑»Õ“®‡≈◊Õ°„™â«‘∏’∑’˺ ¡º “π°—𠇙àπ ª√–‡∑»‡¬Õ√¡π’

®ÿ¥μ—¥«—ππÕπ —Èπ°«à“‡°≥±å‡ªìπ 1/3 ¢Õß§à“«—ππÕπ‡©≈’ˬ

À√◊ÕμË” ÿ¥ 2 «—π ·≈–®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å§◊Õ§à“«—π πÕπ‡©≈’ˬ + 2 ‡∑à“¢Õß à«π‡∫’ˬ߇∫π¡“μ√∞“π ( Ÿß ÿ¥‰¡à‡°‘π 17 «—π)⁽²³⁾  ”À√—∫ª√–‡∑»Ω√—Ë߇»  ∂â“«—ππÕπ‡©≈’ˬ‰¡à‡°‘π 8 «—π

®–‰¡à¡’®ÿ¥μ—¥«—ππÕπ —Èπ (low trim point: LTP) ∂â“«—ππÕπ

‡©≈’ˬ¡“°°«à“À√◊Õ‡∑à“°—∫ 8 «—π ®÷ß®–¡’∑—Èß®ÿ¥μ—¥«—ππÕπ —Èπ

·≈–π“π‡°‘π‡°≥±å⁽²⁴⁾

„πª√–‡∑»‰∑¬π—Èπ °“√æ—≤π“°≈ÿà¡«‘π‘®©—¬‚√§√à«¡ ‡√‘Ë¡

μ—Èß·μàªïæ.». 2536 ‡¡◊ËÕ‡√‘Ë¡∫—ߧ—∫„™âæ√–√“™∫—≠≠—쑧ÿ⡧√ÕߺŸâ ª√– ∫¿—¬®“°√∂ °“√μ—¥¢âÕ¡Ÿ≈μâπ∑ÿπ·≈–®”π«π«—ππÕπ‚√ß æ¬“∫“≈∑’ˇªìπ outliers °√–∑”‚¥¬„™â§à“ ∂‘쑇æ◊ËÕ¥Ÿ°“√°√–®“¬

(coefficient of variation: CV) À“°¡’§à“ CV ¡“°°«à“ 1.50⁽²⁵⁾

·≈–„π°“√»÷°…“°≈ÿà¡«‘π‘®©—¬‚√§√à«¡¢ÕߺŸâ∑’Ë —ߧ¡§«√™à«¬

‡À≈◊Õ‡°◊ÈÕ°Ÿ≈ ‰¥â∑¥≈Õß„™â®ÿ¥μ—¥ÕÕ°∑’ˇªÕ√凴Áπ‰∑≈å∑’Ë 75 ·≈–

97⁽²⁶⁾ ·≈–μ—Èß·μà°≈ÿà¡«‘π‘®©—¬‚√§√à«¡©∫—∫∑’Ë 2 „™â¢âÕ¡Ÿ≈ºŸâªÉ«¬

∑’Ë¡’«—ππÕπ‚√ß欓∫“≈¡“°°«à“ 0 «—π ·≈–„™â‡ªÕ√凴Áπ‰∑≈å∑’Ë 97

‡ªìπ®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å⁽⁵⁾ ‚¥¬ √ÿª ªí®®ÿ∫—π®–„™â®ÿ¥

μ—¥«—ππÕπ —Èπ°«à“‡°≥±å §◊Õ 1/3 ¢Õß§à“«—ππÕπ‡©≈’ˬ ·≈–

®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å §◊Õ „™â§à“‡ªÕ√凴Áπ‰∑≈å∑’Ë 97⁽²⁷⁾

°“√®à“¬‡ß‘π ”À√—∫ºŸâªÉ«¬μ°‡°≥±å (Outlier payment)

⁽²⁸⁾

πÕ°‡Àπ◊Õ®“° Ÿμ√°“√μ—¥ºŸâªÉ«¬μ°‡°≥±å·≈â« °“√®à“¬‡ß‘π

„Àâ°—∫ºŸâªÉ«¬°≈ÿà¡¥—ß°≈à“«§«√®–μâÕß¡’°“√ª√—∫Õ—μ√“∑’Ë®–®à“¬

‡ß‘π„Àâ·°à ∂“π欓∫“≈ ‡æ◊ËÕ°àÕ„À⇰‘¥§«“¡¬ÿμ‘∏√√¡·°à∑—ÈߺŸâ

®à“¬‡ß‘π·≈–ºŸâ„Àâ∫√‘°“√ · ¥ß¥—ß„π√Ÿª∑’Ë 1

 Ÿμ√∑’Ë„™â®à“¬‡ß‘π ”À√—∫ºŸâªÉ«¬«—ππÕπ —ÈπÀ√◊Õπ“π‡°‘π

‡°≥±å„πª√–‡∑»ÕÕ ‡μ√‡≈’¬ ¡’μ—«·ª√ ”§—≠ §◊Õ ®ÿ¥μ—¥«—π πÕπ —Èπ (low boundary point: LBP) ®ÿ¥μ—¥«—ππÕππ“π (high boundary point: HBP) §à“‡©≈’ˬ«—ππÕπª°μ‘ (aver- age length of stay) ·≈–Àπ÷ËßÀπ૬πÈ”Àπ—° —¡æ—∑∏å∑’Ë®à“¬

‡ß‘π ”À√—∫ºŸâªÉ«¬∑’ËÕ¬Ÿà„π‡°≥±å ‡√’¬°«à“ weighted inlier equivalent separation (WIES) ´÷Ëß®–π”¡“§”π«≥Õ—μ√“

°“√®à“¬‡ß‘π ”À√—∫ºŸâªÉ«¬∑’Ë¡’«—ππÕπ —Èπ·≈–π“π‡°‘π‡°≥±å⁽²⁹⁾

‚¥¬√—∞«‘°μÕ‡√’¬ ª√–‡∑»ÕÕ ‡μ√‡≈’¬®–¡’°“√®à“¬‡ß‘π ”À√—∫

ºŸâªÉ«¬∑’ËπÕππ“π‡°‘π®ÿ¥μ—¥«—ππÕππ“π ¥â«¬Àπ૬πÈ”Àπ—°

 —¡æ—∑∏å∑’ËÕ¬Ÿà„π‡°≥±åª°μ‘·≈–‡æ‘Ë¡¥â«¬μâπ∑ÿπμàÕ«—ππÕπ∑’Ë π“π‡°‘π‡°≥±å⁽³⁰⁾

μ—«Õ¬à“߇™àπ „π√Ÿª∑’Ë 1 °√≥’ºŸâªÉ«¬„π°≈ÿà¡«‘π‘®©—¬‚√§√à«¡

¡’«—ππÕπ‡©≈’ˬ 9 «—π πÈ”Àπ—° —¡æ—∑∏凪ìπ 1.000 ·≈–Õ—μ√“

°“√®à“¬‡ß‘π„Àâ‚√ß欓∫“≈μàÕ 1 √“¬ §◊Õ $1,155 ¡’®ÿ¥μ—¥«—π πÕπμË”°«à“‡°≥±å∑’Ë 3 «—π ·≈–®ÿ¥μ—¥«—ππÕππ“π‡°‘π‡°≥±å∑’Ë

√Ÿª∑’Ë 1 «‘∏’°“√®à“¬‡ß‘π°√≥’ºŸâªÉ«¬„π‚√ß欓∫“≈∑’Ë¡’«—ππÕπμà“ß°—π„π°≈ÿà¡ DRG ‡¥’¬«°—π ªï§.».1994-1995⁽²⁶⁾

27 «—π ®–‰¥â‡ß‘π§à“√—°…“欓∫“≈ ¥—ßπ’È

∂⓺ŸâªÉ«¬√—°…“«—π‡¥’¬« (same day)  ∂“π欓∫“≈®–

‰¥â‡ß‘π 0.233 ‡∑à“¢Õߧà“√—°…“欓∫“≈μàÕ√“¬À√◊Õ‡∑à“°—∫ $269

∂⓺ŸâªÉ«¬¡’«—ππÕπ«—π‡¥’¬«  ∂“π欓∫“≈®–‰¥â‡ß‘π 0.333

‡∑à“¢Õߧà“√—°…“欓∫“≈μàÕ√“¬À√◊Õ‡∑à“°—∫ $385

∂⓺ŸâªÉ«¬¡’«—ππÕπ 2 «—π  ∂“π欓∫“≈®–‰¥â‡ß‘π 0.667

‡∑à“¢Õߧà“√—°…“欓∫“≈μàÕ√“¬À√◊Õ‡∑à“°—∫ $770

∂⓺ŸâªÉ«¬¡’«—ππÕπÕ¬Ÿà√–À«à“ß 3-27 «—π ‚√ß欓∫“≈®–

μ“√“ß∑’Ë 3 «‘∏’°“√À“®ÿ¥μ—¥ºŸâªÉ«¬μ°‡°≥±å·≈–°“√®à“¬‡ß‘π„Àâ°≈ÿࡺŸâªÉ«¬μ°‡°≥±å⁽³⁰⁾

°“√®à“¬‡ß‘π°≈ÿà¡μ°‡°≥±å (outlier payment)

ª√–‡∑» «‘∏’°“√μ—¥ºŸâªÉ«¬μ°‡°≥±å °“√ª√—∫≈¥ °“√ª√—∫‡æ‘Ë¡

(trimming method) (deduction) (surcharge)

ÕÕ ‡μ√’¬ «—ππÕπ (interquartile) μàÕ«—ππÕπ μàÕ«—ππÕπ

Õ—ß°ƒ… «—ππÕπ (interquartile) ‰¡à¡’°“√ª√—∫≈¥ μàÕ«—ππÕπ

·μà«—ππÕπ —Èπ®–¡’Õ—μ√“ (tariff)

‡Õ ‚μ‡π’¬ μâπ∑ÿπ (parametric) - μ“¡√“¬°“√

øîπ·≈π¥å μâπ∑ÿπ (parametric) ‰¡à¡’°“√ª√—∫≈¥ μ“¡√“¬°“√

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·μà«—ππÕπ —Èπ®–¡’Õ—μ√“ (tariff)

‚ª√μÿ‡°  «—ππÕπ (interquartile) μàÕ«—ππÕπ μàÕ«—ππÕπ

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 «’‡¥π μâπ∑ÿπ/«—ππÕπ (parametric) ·μ°μà“ß°—π ·μ°μà“ß°—π

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1. Fetter RB, Freeman JL. Diagnosis related groups: product line management within hospitals. Acad Manage Rev 1986;11(1):41- 54.

2. Vertrees JC, Manton KG. Using case-mix for resource allocation.

In: Casas M, Wiley MM, editors. Diagnosis related groups in Europe: uses and perspective. Heidelberg: Springer-Verlag Berlin Heidelberg, 1993:155-172.

3. Scheller-Kreinsen D, Geissler A, Busse R. The ABC of DRGs.

Euro Observer 2009;11(4):1-4.

4. McMahon LF, Shapiro LR, Weissfeld LA, Billi JE. Prior hospital- ization experience of DRG outliers versus inliers. Med Care 1988;

26(4):423-9.

5. Pannarunothai S. Diagnosis related groups: principle and practice.

Phitsanulok: Centre for health equity monitoring, Naresuan Uni- versity; 1999. (in Thai)

6. Accardo FM, Domiani P, Damiani F, Geraci A, Tomasello G.

Diagnosis related group analysis and strategic healthcare budget- ing. Capsula Eburnea 2011;6(21):103-6.

7. National Health Security Office. Thai Diagnosis Related Groups Version 4 Volume 1 and 2. Nonthaburi: National Health Security Office; 2007. (in Thai).

8. National Health Security Office. Thai Diagnosis Related Groups Version 5 Volume 1 and 2. Nonthaburi: National Health Security Office; 2012. (in Thai).

9. Felder Stefan. The variance of length of stay and the optimal DRG outlier payments. Int J Health Care Finance Econ 2009;9(3):279- 89.

10. Ginsberg S, editor. Evaluating various trimming methodologies to set cost weights based on diagnostic related grouping (DRG) for south in hospital events. 25th PCSI Conference in Fukuoka; 2009 Nov 11-14; Fukuoka, Japan.

11. Palmer G, Reid B. Evaluation of the performance of diagnosis- related groups and similar casemix systems: methodological is- sues. Health Serv Manage Res 2001;14:71-81.

12. Pirson M, Martins D, Jackson T, Dramaix M, Leclercq P. Pro- spective casemix-based funding, analysis and financial impact of cost outliers in all-patient refined diagnosis related groups in three Belgian general hospitals. Eur J Health Econ 2006;7:55-65.

13. Schreyogg J, Stargardt T, Tiemann O, Busse R. Methods to deter- mine reimbursement rates for diagnosis related groups (DRG): a comparison of nine European countries. Health Care Manage Sci 2006;9:215-23.

prices: how well do prices reflect costs in the German DRG- system?. Health Care Manage Sci 2006;9:269-79.

24. Bellanger MM, Tardif L. Accounting and reimbursement schemes for inpatient care in France. Health Care Manage Sci 2006;9:295- 305.

25. Kunarattanapruk S, Pannarunothai S, Wongkanaratanakul P, Supachutikul A, Kingkaew P. Medical care price schedules for road traffic accidents: the Thai DRG for accidents. Nonthaburi:

Health System Research Institute; 1995. (in Thai)

26. Pannarunothai S, Wongkanaratanakul P, Boonpadung D, Kamtue S. Diagnosis related groups for the low income patients. Nonthaburi:

Health System Research Institute; 1997. (in Thai)

27. National Health Security Office. Thai Diagnosis Related Groups Version 3 Volume 1 and 2. Nonthaburi: National Health Security Office; 2003. (in Thai)

28. NSW Health and community services. Casemix funding for public health 1994-95. Melbourne: Health and Community Services; 1994.

29. Jackson T. Using computerized patient-level costing data for set- ting DRG weights: the Victorian (Australia) cost weight studies.

Health Policy 2001;56:149-63.

30. Busse R, Geissler A, Quentin W, Wiley M (editors). Diagnosis- related groups in Europe moving towards transparency, efficiency and quality in hospitals. World Health Organization: the European Observatory on Health Systems and Policies; 2011.

31. Scheller-Kreinsen D, Quentin W, Busse R. DRG-based hospital payment systems and technological innovation in 12 European countries. Value in Health 2011;14:1166-72.

14. Shahram G, Jackson TJ, Doran CM, Wilson A, Aisbett C. De- scribing Iranian hospital activity using Australian Refined DRGs:

a case study of the Iranian social security organisation. Health Policy 2008;87:63-71.

15. Ellis RP, McGuire TG. Insurance principles and the design of prospective payment systems. Journal of Health Economics 1988;7:215-37.

16. Luc Schenker, Hermann Pl_ss, Brian Frischknecht, Herv_ Guillain, Jean-Claude Rey. APDRG cost weights - version 4.1. Institut de santé et d‘économie (ISE), Switzerland.

17. Duckett S. Casemix funding for acute hospital inpatient services in Australia. Medical Journal of Australia 1998;169(8):17-21.

18. Berki SE, Schneier NB. Frequency and cost of diagnosis-related group outliers among newborns. Pediatrics 1987;79(6):874-81.

19. Cots F, Elvira D, Castells X, Dalmau E. Medicateûs DRG-weights in a European environment: the Spanish experience. Health Policy 2000;51:31-47.

20. Gong Z, Duckett SJ, Legge DG, Pei L. Describing Chinese hospi- tal activity with diagnosis related groups (DRGs): a case study in Chengdu. Health Policy 2004;69:93-100.

21. Cots F, Elvira D, Castells X. Relevance of outlier cases in case mix systems and evaluation of trimming methods. Health Care Management Sci 2003;6:27-35.

22. Pirson M, Dramaix M, Leclercq P, Jackson T. Analysis of cost outliers within APR-DRGs in a Belgian general hospital: two complementary approaches. Health Policy 2006;76(1):13-25.

23. Schreyogg J, Tiemann O, Busse R. Cost accounting to determine