1

Summary
Utilization Review Case Sectio Caesarea PostImplementation Indonesia Case-Based Groups
(INA-CBG's) in RSUD Bima

Firman
10/308530/PKU/11793

GRADUATE PROGRAM
MASTER OF HOSPITAL MANAGEMENT
MEDICAL FACULTY OF GADJAH MADA UNIVERSITY
YOGYAKARTA
2011

Utilization Review Case Caesarean Section PostImplementation Indonesia Case-Based Groups

(INA-CBG's) in RSUD Bima
Firman1, Valentina Dwi Yuli S2,Tjahjono Koentjoro3

ABSTRACT

Background: Health care costs tend to increase. It would require efforts to

control costs and quality. Efforts are made through the government's
determination INA-DRG/INA-CBGs tariff pattern. INA-CBGs tariff pattern is not
entirely in accordance with the pattern of prevailing rates in the hospital. So the
question arises of research How Utilization Review (UR) cases Caesarean
Section (CS) post-implementation INA-CBGs.
Objective: This study to conduct Utilization Review: Admission and concurrent
review of Caesarean Section cases post-implementation INA-CBG's in RSUD
Bima.
Research methods with deCSriptive case studies with the unit of analysis is the
Jamkesmas patient who underwent CS surgery. The sample size is the total
population found during the study period.
Results: Utilization review is performed on admission procedures appropriate
review standard is at 100%. In the procedure reached 67% Concurrent Review.
Overall, 70% of procedures performed on patients Jamkesmas CS cases have
been in accordance with standards / guidelines. The average length of stay
patients was 4.27 days. None of the patients who experienced complications.
The average cost of which is claimed by the pattern of INA-CBG's tariff is Rp.
1,243,983 (including pharmaceuticals). While the average cost for the 30
respondents to rate the hospital (Perda) is Rp. 1.769.000 (excluding
pharmaceuticals). The average cost of drugs for patients Jamkesmas is Rp. 651
667 per patient.
Conclusion: Utilization Review in the case of CS after execution of INA-CBG's
that almost all the main procedures have been performed. Yet also still found
the procedure was not performed. In terms of financing patterns INA-CBG's
tariff in case of CS showed a lower number of tariff regulation pattern.
Key words: Utilization Review, CS Case, INA-CBGs.

1 RSUD Bima
2 Panti Rapih Hospital, Yogyakarta
3 Master of Hospital Management, Medical Faculty of Gadjah Mada University

Introduction
According to status (type C) RSUD Bima serve almost all types of
patients including patients Jamkesmas. In addition to the one day care services
and Emergency Department (IGD), patients Jamkesmas in RSUD Bima also
CSattered in Pediactric room, ICU, ICCU, Surgery, Internal Diseases and in the
Maternity Unit. Included also is the department of other supporting services.

Table 1. Patients Jamkesmas Visit in RSUD Bima

Type delivery

2008

2009

2010

One day care

5.150

Patient

4.306

Patient

4.345 Patient

Inpatient

4.555

Patient

4.312

Patient

5.112 Patient

Emergency Department (IGD)

3.182

Patient

3.475

Patient

3.733 Patient

Delivery surgical

246

Patient

360

Patient

502 Patient

Sources : LAKIP RSUD Bima, 2010

For these tariff patients Jamkesmas, since in 2008 the government

implemented

new

policy.

Based

on

Decree

No.

Kepmenkes.

1161/Menkes/SK/X/2007 then arranged and assigned Tariff Hospital by

Indonesia Diagnosis Related Groups (INA-DRG). But since January 2011, the
term INA-DRG later turned into INA-CBG's (Case-Based Groups. INA-CBG's a
continuation of application INA-DRG whose licenses expire on September 30,
2010. Thus the application of INA-CBG's will replace the functionality of the
application INA-DRG. INA-DRG classification itself set any kind of health
services into groups that have relatively the same meaning. In addition, each
patient is treated in a hospital are classified into groups with similar clinical
symptoms as well as maintenance costs are relatively similar.1
One case that uses pattern INA-DRG tariffs are case Cesarean Section
(CS). RSUD Bima in 2010 serving a total of 1628 delivery born with them
through the CS 504 (31%). A study conducted in RSMH revealed that 98.6%
service charge to the patient's operative medical act not in accordance with the
tariff Jamkesmas INA-DRG.2

Research Method and Instruments

The design of this study was a descriptive case study design with a
holistic single case study. This design was chosen because of the problem
under study is a contemporary issue with multisource data and researchers
have a small chance that there is not even to control the events this study.
The unit of analysis in this study were patients Jamkesmas with a case
Caesarean Section in RSUD Bima. The population in this study were all
patients Jamkesmas with CS cases during the period of data collection
research (8 June to 23 July 2011) that as many as 30 patients. Sample size is
total sample. Instrument in this study were Caesarean Section Clinical
guidelines from the National Institute for Clinical Excellence (NICE) for the
National Health Service (NHS), created in the form observation sheet / check
list as well as an interview guide. Analysis techniques used in this study were
obtained quantitative data presented in the form of deCSriptive statistics. For
qualitative analysis is written in clear text or descriptive of the interview.

The results and discussion

1.

Characteristics of Respondents
Table 2. Frequency of respondents patients Jamkesmas CS cases in
RSUD Bima Maternity Unit by Age, Education Level, Type and Time
Operations CS, June-July 2011
Characteristic
Age

Education Level

Type CS

Time Operations CS

Category

17-25
26-40
> 40
SMP
SMA
D3/S1
Weight
Medium
Lightweight
06.00-14.00
15.00-20.00
21.00-05.00

13
15
2
3
24
3
0
3
27
15
8
7

Most of the respondents aged 26-40 years. Under age (17-25

years) also spelled out a lot. This gives the sense that the respondents
were women in the fertile period. Including first-time mother. With the CS
to have an operation, whether it be a child first, second third and so on will
have any impact on subsequent pregnancy and birth plans.
The education level of respondents are predominantly high
CShool. It gives an overview of respondents ability and understanding of
surgery performed. Research conducted Christanti showed a significant
relationship between level of education of patients and their families to the
approval operasi. According to INA-CBG's version, as many as 27 of 30
respondents deCSribed as a Surgical Operation Light Caesar. The
remaining 3 patients deCSribed as Caesar Surgery Operation Medium. No
category Surgery Surgery Weight Caesar among these patients

2.

Admission review
Aspects Indications CS
Based on the observation that CS made against the respondents
indicated the highest is because of premature rupture of membranes
(PROM) as much as 40%. Second, fetal distress (30%), third Placenta
previa (10%), Weight Pre eclampsia (6.7%) and others that Serotinus,
location breech, presentsi face, big baby (13.3%). An audit review of
ministry operations per CS in Ireland found that fetal distress was the main
indication for emergency cesarean (63%) women. Similarly, the research
results Florica, et al explain that fetal distress (1.6%, P =. 0001), is the
highest indication to do CS. Then, at the request of the mother (1.5%, P =.
0001), and dystocia (0.8%, P =. 03) 5, 6
Meanwhile, according to the guideline, CS indications do is 1)
Breech Presentation, 2) Multiple pregnancy, 3) Preterm birth, 4) Small for
gestational

age,

5)

Placenta

previa

6)

predicting

cephalopelvic

disproportion in labor, 7) Mother-to-child transmission of maternal

infections.7

Overall results of utilization review on the admission process is the

appropriate standard of review guidelines is at 100%.

3.

Concurrent Review
a. Aspects of Information
Table 3. Result Utilization Review on Aspects of patient information in
the CS case Jamkesmas Maternity Unit RSUD Bima, June-July 2011
Yes

Information

n
30
18
23
15
16
102

CS Indication
CS Procedure
CS Risk
CS Benefits
CS Implications
Total

No
%
100
60
77
50
53
68

n
0
12
7
15
14
48

%
0
40
23
50
47
32

In aspects of this information, the new overall procedure as

much as 68% of the information provided. The information provided
does not seem consistent between patients with one other patient.
Pregnant women should be informed that based on evidence and
support allow them to make decisions about childbirth. Pregnant
women should be given evidence-based information about the SC
during the antenatal period. This should include information about the
SC, such as: 1) Indications for SC, 2) What procedures are used, 3)
Information that terrkait risks and benefits of SC, 4) Implications for
pregnancy and birth in the future after SC.7
Article 45 Medical Practice Act provides minimum limit
should be information provided to patients, namely: 1) Diagnosis and
medical treatment procedures, 2) objective medical acts performed, 3)
other action alternatives and the risks, 4) risks and complications that
may

occur,

and

5)

Prognosis

of

medical

interventions.8

Have a method that more accurately reflects what can be practiced in a

state of emergency will help communication and potentially save time
and misunderstandings with patients and among tim.9

b. CS Planning Aspects
Table 4 : Result Utilization Review on Aspects of Planning SC SC
cases in patients Jamkesmas Maternity Unit RSUD Bima,
June-July 2011
Yes

CS Planning
Check haemoglobin
Prophylactic cephalosporin
Anaethetic alternative
Easy communication of information
Information based on evidence
CS after 39 weeks
Total

n
14
30
0
26
30
25
125

No
%
47
100
0
87
100
83
69

n
16
0
30
4
0
5
55

%
53
0
100
13
0
17
31

In general in this aspect of the new 69% standard

appropriated. There is a procedure that did not implementation offer.
namely absence of anesthesia. The lack of bids is due to the type of
anesthesia anesthesia personnel who are not specialists anesthesia.
Power that exists only offer this type of anesthesia according to ability
and supplies and materials available. According to the standard
guideline that patients who would be the SC should: be informed and
offered about the different types of analgesia that is best suited to the
needs mereka.7
For laboratory examination of the problem faced was the lack
of a analist standby. This means that in the current RSUD Bima
laboratory staff not on duty for 24 hours. This complicates the
laboratory examination of pre-surgical SC, especially in the afternoon
and evening. Besides, seen from the urgency of the patient. In
emergency patients, when

generally hemodinamik good then the

patient can be directly in the operation.

A study conducted Simm, et al show in Ireland where 20
people (63%) of women in emergency caesarean section with the
indication, only 4 cases performed with blood sampling. Laboratory
tests, especially blood Hb should be done every patient who will be
SC, but for certain patients who are not allowed without the need to
prepare a complication of blood serum before CS.7, 10

c. CS Procedure Aspect
Table 5. Result Utilization Review on Aspects of SC patients
Jamkesmas Procedure case of SC in Maternity Unit RSUD Bima,
June-July 2011
CS Procedure Aspect
Transverse abdominal wall incisions
Use blunt extension
Give Oxcytocin (5 iu)
controlled cord traction placenta
Close the uterine incision with two
suture layers
Facilitate early skin-to-skin contact for
mother and baby
Total

Yes

No

n
2
30
30
30

%
7
100
100
100

n
28
0
0
0

%
93
0
0
0

30

100

30

100

122

68

58

32

Almost all the procedures, especially for safety and patient

safety have been implemented. But one procedure the initial contact
with the baby it nothing is done. The new baby is issued through direct
operations taken by officers (doctors, nurses) space intermediate care
neonatal SC. After that the baby will live on for help and provided care
in the NICU. So the initial contact with new mothers do when the
mother has been realized and the baby's condition has been good.
Model surgical incisions in the abdominal wall almost
entirely made midline or not with transverse incisions. With a midline
incision model / Vertical this will be easier to open the abdominal wall.
This model is the model / type of incision is usually applied to the SC
surgery patients in the classroom III. That is, this model does not only
apply to patients Jamkesmas also common in patients who were
treated in the classroom III. To oksitocyn, in RSUD Bima not just 5 iu a
given, but more often 10 iu. It is usually given after the baby is born.
Doses will be added when the contraction of the uterine is not good.

d. Baby care after CS

Table 6. Results of the UR on Aspects of Baby care after CS in the
Maternity Unit RSUD Bima, June-July 2011
Baby care after CS
Presence of paediatrician at CS
Risk Evaluation
Thermal care for babies born by CS
Maternal contact (skin to skin)
Start
breastfeeding as soon possible
Total

Yes

No

n
0
30
30
28

%
0
100
100
93

n
30
0
0
2

%
100
0
0
7

29

97

117

78

33

22

Important procedure that is never done on this aspect is the

absence of a pediatrician. Your child's doctor will be present only when
there are problems or fetal distress. Because if there is no problem
baby will be directly brought into the NICU. The presence of any
pediatrician in practice during the time of the study is only done by his
assistant (general practitioner).
All newborn care procedures performed in the NICU.
Including the evaluation of infant health risks and environmental
temperature for baby. Encouragement direct contact with the mother
do when the baby's condition and circumstances of both her mother
had been aware or generally good condition. Baby immediately
transfer to his mother for rooming and initiate contact with his mother.
When you first contact the mother and baby, nurses assist and
motivate efforts to proficiency level. Including encouragement to early
initiation of breastfeeding (breastfeeding immediately when it is
possible for both mother and baby)

10

e. Aspect Care of the woman after CS

Table 7: Results UR Care of the woman after CS Aspect of patients
Jamkesmas Post CS cases in Maternity Unit RSUD Bima,
June-July 2011
Yes
Care of the woman after CS
Help women to start breastfeeding
Women should be offered diamorphine
Offer NSAI drugs
Early eating and drinking
Urinary catheter removal after 12 hours
Remove wound dressing after 24 hours
Discuss the reasons for the CS and
implications
Offer earlier discharge (after 24 hours)
Offer postnatal care
Prescribe regular analgesia
Monitor wound healing
Inform women they can resume
activities
Total

No

n
29
0
6
21
30
30

%
97
0
20
70
100
100

n
1
30
24
9
0
0

%
3
100
80
30
0
0

19

63

11

37

0
19
30
30

0
63
100
100

30
11
0
0

100
37
0
0

16

53

14

47

230

64

130

36

Aspects of maternal care on the SC post this most important

procedures have been implemented. Some were not implemented at
all. This corresponds to a standard that is owned hospitals. Offer postSC treatments performed by explaining what should be done by the
mothers after hospital discharge. Including offering to perform
maintenance at the nearest health service or hospital. For activity
information that can be done while the patient is given the SC post will
be home. Women with SC should be offered the opportunity to discuss
with their healthcare providers the reasons for the SC and the
implications for the future of the child or kehamilan.7
After the SC women should be observed on the basis of oneon-one with properly by trained staff members until they return airway
control and cardiorespiratory stability and are able to communicate.
After recovery from anesthesia, observations (respiratory, heart rate,
blood pressure, pain and sedation) should be continued every half hour
for two hours. If the observations are not stable, more frequent
observations and medical review are recommended. For women who

11

have given intrathecal opioids, there should be a minimum value of the

observation level, sedation and respiratory illness for at least 12 hours
for diamorphine and 24 hours for morfin.7

f.

Length of Stay (LOS)

Table 8. Frequency of Utilization Review on Aspects of Length of Stay
of patients in the SC case Jamkesmas Maternity Unit RSUD Bima,
June-July 2011
Yes

LOS
LOS 3-4 days
Total

n
20
20

No
%
66,7
66,7

n
10
10

%
33,3
33,3

Length of Stay for patients Jamkesmas with cases of SC

ranged between 3-6 days. Standard discharge of patients in hospitals
Bima SC is 4 days. Patients who go home on day 3 is usually because
the request itself. While returning more than 4 days because of the
general situation that has not been a good mother or her unborn
healthy state.

g. Complication
Table 9. Results of Utilization Review on Aspects of patient
Jamkesmas SC case complications in the Maternity Unit RSUD Bima,
June-July 2011
Complication
No Complication
Total

Yes
n
30
30

No
%
100
100

n
0
0

%
0
0

The average patient hospitalized Jamkesmas who could be

discharged on day 4 post-surgery. This means that the average patient
no complications during the post-surgical care / SC operations.

Overall results of utilization review on Concurrent process is the

appropriate standard of review guidelines is 67% .

12

While the whole process of admission and concurrent review

is 68%. McGlynn et al (2003) in the NEJM as cited Healy (2011) that
only 55% of patients in the USA receive recommended care. This
situation is one type of Under use of what he called "Poor quality health
care". Included also in this type of low quality of health services is
Over-use form: unnecessary treatment, such as tests and procedures,
birth through SC and tonsilectomy. As for the Misuse of type categories
include: misdiagnosis, medication errors and prosedur.11

h. Financing
The amount of claim costs of patient care with the pattern of
tariff INA-CBG's well with the pattern of the general rate / regulations
as well as the cost of the use of drugs and medical devices for patients
Jamkesmas with the case of CS, showed that the average tariff INACBG's for patients who were respondents amounted Rp. 1,243,983.
The average cost for 30 patients when respondents using the hospital
pattern of tariff rates (Perda) is Rp. 1.769 million. Average cost of
medicines and medical equipment amounted to Rp. 651 667 per
patient. The average difference in cost if it also includes the cost of
medicines is Rp. 1,176,684 per patient.
These rates are much lower when compared with the standard
of NICE in the UK. This is consistent with previous research done by
Septianis 98.6% who said that the cost of medical care measures in
patients Jamkesmas operative in RSMH accordance with the tariff not
INA-DRG.2 A study in Korea showed there is actually no significant
difference between the pattern of rates made by the model with the
pattern of DRG tariff system model developed by the local hospital.
"There was no significant difference between the CS level of service
providers in the DRG and fee-for-service system. CS level did not vary
significantly depending on the period of service providers DRG. The
results provide evidence that the DRG payment system operated by a
voluntary health care organizations had no impact on the level of CS,

13

which can degrade the quality of care. Although providers joined DRG
system in different years, these results support the expanded use of
DRG-based DGR future ".12

Conclusion
1.

Utilization Review in the admission review process showed that all

patients performed Jamkesmas SC indications are compliant (100%).

2.

At this stage of Concurrent review of some procedures not done at all. But
the important procedures related to patient safety have been conducted.
There was no incidence of complications. The average length of
hospitalization days was 4.27 days. Overall results on Concurrent Review
procedures that follow the standard guideline is 67%. Overall average on
admission procedures and concurrent review was done according to
appropriate standards amounted to 68%.

3.

Compared with hospital rates based on the legislation, the pattern of INACBG's tariffs in case of SC showed a lower number. Where the average
cost for the 30 respondents with a pattern of INA-CBG's tariff of Rp.
1,243,983 (including the cost of drugs) while the average tariff charged by
the hospital (Perda) is Rp. 1.769 million (not including the cost of drugs).
The average cost of drugs and medical devices for patients Jamkesmas is
Rp. 651 667 per patient.

Suggestion
1.

So that hospitals can perform quality control efforts and control costs by
effective real need to formulate policies related to the management of
patients including patients Jamkesmas this SC. One way is to establish
standard operating procedures and clinical pathway of each case including
the SC and implement a policy of one daily dose (ODD) in prescribing the
drug.

2.

To the Government (Kemenkes), maker of DRG-related action the SC to

re-evaluate in detail the cost of SC action package.

14

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Jamkesmas. Jakarta: Ditjen Bina Pelayanan Medik.
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