Impact of Hospital Payment Reform on Rational Use of Antibiotics: A natural experiment

Kun Zou^1,2Xiaofan Peng^3*Yue Huang⁴Jin-Min Shi⁵Zhong-Cheng He⁶Yi-Jia Hao³Chaojie Liu⁷Yong Tang⁴Shaoyang Zhao⁴Yong-Mu Jiang⁴Imti Choonara⁸Lingli Zhang^1,2,9

• ¹Sichuan University West China Second University Hospital Department of Pharmacy, Chengdu, China
• ²Sichuan University West China Second University Hospital Sichuan Provincial Key Laboratory of Development and Women and Children's Diseases, Chengdu, China
• ³Sichuan University West China School of Public Health, Chengdu, China
• ⁴Sichuan University, Chengdu, China
• ⁵Wuhan University Economics and Management School, Wuhan, China
• ⁶Guangyuan Human Resources and Social Security Bureau, Guangyuan, Sichuan Province, China, Guangyuan, China
• ⁷La Trobe University School of Psychology and Public Health, Melbourne, Australia
• ⁸University of Nottingham School of Medicine, Nottingham, United Kingdom
• ⁹West China Hospital of Sichuan University Chinese Evidence-based Medicine Center, Chengdu, China

While numerous studies have examined the effects of diagnosis-related groups (DRG) payment on hospital healthcare, evidence regarding its impact on the quality of hospital healthcare is poor and findings have been inconsistent. This study evaluates how DRG payment reform influences rational use of antibiotics in hospital using the World Health Organization (WHO) Access, Watch, Reserve (AWaRe) classification in China. We employed a natural experiment design with difference-in-differences analysis, comparing 10 hospitals implementing DRG payment in two pilot cities with 27 hospitals maintaining fee-for-service (FFS) payment in three control cities in Sichuan Province. Using medicine consumption data from 2016-2020 (185 hospital-years), we assessed total antibiotic use/expenditure, Access/Watch group proportions, and Access-to-Watch ratios. Compared with FFS payment, DRGs payment had no significant impact on the total quantity or expenditure of antibiotic use. However, DRGs payment led to -13.01% (95% CI: -25.32% to - 0.70%) reduction of proportion of Access antibiotics use and 13.90% (95% CI: 1.97% to 25.83%) increase of proportion Watch antibiotics use. Subgroup analysis showed similar results in both secondary and tertiary hospitals, but greater in the former. DRGs hospital payment reform may not affect the total quantity or expenditure of antibiotics use, but decrease the proportion of WHO Access antibiotics use and increase the Watch antibiotics use. Close monitoring and interventions are warranted to improve rational use of antibiotics for health systems during hospital payment reform.