Rational Design and Effectiveness Analysis of Pediatric Medication Pathways under DRG/DIP Payment Models

Abstract Objective To evaluate the impact of implementing pediatric medication pathways on operational management under the DRG/DIP payment model in a specialized children’s hospital, using DRG as a case study. Methods All medical records with DRG codes DT13 and GW15 from 2023 (pre-implementation control group) and 2024 (post-implementation observation group) were included. A systematic comparative analysis of clinical data was performed to assess the effects on hospital operational metrics. Results The observation group exhibited a significantly lower average cost per case (DT13: 17.82%; GW15: 26.05%) and a higher medical insurance payment margin (DT13: ¥186,500; GW15: ¥89,000) compared to the control group. The examination cost proportion and total hospitalization expenses decreased significantly (P < 0.05), whereas the drug cost proportion showed a non-significant decreasing trend (P > 0.05). Regarding efficiency, the average length of stay and number of drug varieties were significantly reduced (P < 0.05). Quality indicators, including antibiotic usage rate, antibiotic use intensity, and adverse drug reaction incidence, were significantly improved (P < 0.05), alongside an increased rational prescription review rate. Furthermore, the number of high-cost cases decreased while low-cost cases increased for both disease groups post-implementation, with all case distributions remaining within clinically acceptable bounds. Conclusion Pediatric medication pathways represent an effective strategy for balancing cost-containment with the unique clinical demands of pediatric care within the DRG/DIP framework. They provide a practical reference for precision management in pediatric hospitals and empirical evidence to inform pediatric-sensitive medical insurance payment policies.