OBJECTIVES: Case-mix classifies patients and associated costs by Diagnosis-Related Group(DRG) and the application of Clinical Pathways(CP). Previous studies have reported discrepancies between rates estimated from case-mix and actual costs, particularly for deliveries. The aim of this study is to determine the discrepancy between tariffs and patient-level costs in the management of spontaneous vaginal delivery(SVD) and lower segment caesarean section(LSCS) in a tertiary hospital in Malaysia.

METHODS: A cross-sectional study was conducted in which annual data on DRG, case-mix tariffs and resource utilizations were collected. CP were obtained through a series of face-to-face interviews with local clinical experts and tariffs were estimated accordingly. Unit costs were obtained from the Hospital Cost Information System. All costs and tariffs were expressed in 2020 USD.

RESULTS: There were 2652 admitted SVD/LSCS cases with different case-mix severities. The DRGs for SVD are O-6-13-I(n=2080), O-6-13-II(n=8) and O-6-13-III(n=1). The DRGs for LSCS are O-6-10-I(n=557), O-6-10-II(n=5) and O-6-1-III(n=1). The average length of stay (and tariffs compared to average patient-level costs) for O-6-13-I, O-6-13-II, O-6-13-III, O-6-10-I, O-6-10-II, and O-6-1-III, were 3.8 (USD$2365 compared to 6909), 3.9 (USD$2920 compared to 7548), 5 (USD$3123 compared to 8213), 4.6 (USD$2985 compared to 1645), 6.6 (USD$3892 compared to 11096) and 5 (USD$10924 compared to 8176) respectively. Costs were higher compared to the case-mix tariffs. There were inconsistencies between resource utilizations among patients which results in a wide range of costs across all DRGs and non-compliance used of CP.

CONCLUSIONS: This study highlights the inconsistency of resource utilization of treating patients in the same DRG due to the non-compliance used of CPs. It shows that the costs incurred were higher than the case-mix tariffs, which could be due to inefficient utilization of resources. This study emphasizes the potential role of CPs in ensuring efficient clinical management through the implementation of case-mix to improve hospital efficiency and resource utilization.