目的:在按疾病诊断相关分组（DRG）改革与耗材集采背景下,评估新疆心力衰竭患者植入式心律转复除颤器（ICD）植入的经济负担,剖析医保待遇差异。方法:回顾性分析新疆某三甲医院（以下简称“样本医院”）2021—2025年975例首植患者数据。利用回归模型分析住院费用、自付比例及高医疗负担（自付>5万元）的影响因素。结果:住院总费用中位数13.02万元,耗材占72.5%。城乡居民基本医疗保险（以下简称居民医保）自付比例中位数高于职工基本医疗保险（以下简称职工医保） （0.30 vs 0.20,P<0.001）。多因素Logistic回归显示,居民医保发生高医疗负担风险高于职工医保（OR=2.34,95% CI：1.45-3.78）,全皮下植入式心律转复除颤器（S-ICD）亦显著增加高医疗负担风险（OR=3.50,95% CI：1.42-8.60）。随访期间全因再入院率达43.9%,再入院中位费用为1.01万元。结论:新疆心衰患者ICD植入费用以耗材支出为主,不同医保制度间患者自付负担差异显著;S-ICD等高值耗材在居民医保参保人群中可能进一步放大经济负担。建议持续推进区域高值耗材集采并完善DRG支付标准,探索耗材除外支付或特例单议等精细化支付机制;同时加快ICD植入术后程控与远程监测等医疗服务项目立项,明确收费与监管规范,推动其按规定纳入医保支付范围,以促进全周期规范化管理并降低再入院风险。
Abstract
Objective:The paper evaluates the economic burden of implantable cardioverter-defibrillator (ICD) implantation in patients with heart failure (HF) in Xinjiang under DRG reform and centralized procurement of medical consumables, and to analyze disparities between health insurance schemes. Methods:We retrospectively analyzed 975 patients undergoing first-time ICD implantation at a tertiary hospital in Xinjiang, China, from 2021 to 2025. Regression models were used to assess determinants of inpatient costs, out-of-pocket (OOP) proportion, and high medical burden (OOP > 50000 yuan). Results:The median total inpatient cost was 130200 yuan, with medical consumables accounting for 72.5%. The median OOP proportion was higher in the Urban and Rural Resident Basic Medical Insurance (URRBMI) than in the Employees’ Basic Medical Insurance (EBMI) (0.30 vs 0.20, P<0.001). In multivariable logistic regression, URRBMI was associated with a higher risk of high medical burden compared with UEBMI (OR=2.34, 95% CI: 1.45-3.78), and subcutaneous ICD (S-ICD) further increased the risk (OR=3.50, 95% CI: 1.42-8.60). During follow-up, the all-cause readmission rate was 43.9%, and the median readmission cost was 10100 yuan. Conclusions:The cost of ICD implantation for HF patients in Xinjiang is primarily composed of consumable expenses, and marked disparities in OOP burden exist across insurance schemes in Xinjiang, and high-cost cardiac devices/consumables such as S-ICD may further amplify the economic burden among URRBMI beneficiaries. It is recommended to continue promoting regional centralized procurement of high-cost consumables and refining DRG payment standards, while exploring refined payment mechanisms such as payment exclusion for consumables or case-by-case special review. Meanwhile, efforts should be accelerated to establish post-implantation programming and remote monitoring of ICD as medical service items, with clear charging and regulatory standards, and to promote their inclusion into the scope of medical insurance coverage in accordance with regulations, so as to facilitate full-cycle standardized management and reduce the risk of readmission.
关键词
心力衰竭 /
植入式心律转复除颤器 /
医保支付方式改革 /
疾病经济负担 /
真实世界研究
Key words
heart failure /
implantable cardioverter-defibrillator /
medical insurance payment method reform /
economic burden of disease /
real-world study
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基金
国家自然科学基金“基于创新扩散理论的区域医疗一体化对新疆基层医疗机构合理用药的影响及优化策略研究”（72464032）; 新疆维吾尔自治区自然科学基金-青年科学基金“大数据驱动的医保基金监督管理与决策模式创新研究”（2024D01C292）; 新疆维吾尔自治区重点研发计划“心血管疾病多模态队列数据库建立及数字化个体智能预测模型研发和转化”（2022B03023）
