Knowledge, Attitude and Perception on Casemix System Among the Hospital Staff in Malaysia and Indonesia
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Objective: Aim of this study is to assess the Knowledge, Attitude & Perception (KAP) among the hospital staff regarding Casemix Objective: The aim of this study is to assess the Knowledge, Attitude, and Perception (KAP) of hospital staff regarding the Casemix System in Developing countries. Methods: A cross-sectional study was carried among the hospital staffs in Indonesia and Malaysia. The study hospitals and respondents were selected via random and purposive sampling, respectively. Data was collected via self-administered questionnaires. Results: Total 350 hospital staffs participated, out of this 58.6% of participants were from Indonesia. Most of the respondents (58.0%) had a moderate level of knowledge score, medium level of perception score (84.9%) and negative attitude (90.0%) on Casemix. The study found that years of working experience, type of occupation, hospital type, country, and those with training in Casemix were significantly related to knowledge score. No independent variable except for country was related to perception score. It was also found that majority (66.7%) of the participating hospitals (N=36) completely captured the demographic data in their HIS, 47.2% completely implementing the coding module as per Casemix requirement and 27.8% of the hospitals recorded the Activity Daily Living (ADL) score in their system. Conclusion: Among the participants, only 2.3% demonstrated a high level of knowledge about Casemix. When it comes to attitudes, majority of respondents expressed a negative view towards Casemix. Regarding perceptions, only 11.4% of respondents had a high perception of Casemix, while the majority, 84.9%, had a medium perception.
Introduction
The idea of using Casemix classification to
manage hospital services has existed for some time but was limited by
technology. It was only after Medicare was introduced in 1965 that serious
efforts to measure hospital production and control costs began [1]. Casemix was developed by Robert B Fetter for
managing patients in hospitals, Casemix systems are continuous learning systems
which aim to improve transparency, efficiency and quality in health service
provision[2]. Casemix systems are subject to the specific health
system they are embedded in and they can constitute powerful incentive
mechanisms within the health system[3]. Casemix systems, as important tools for
resource distribution within health systems, are subject to various influences
and vested interests that go beyond predictive ability and homogeneity in case
groups[4]. They introduced a standardized method for
describing the product of health services and their respective resource
utilization while linking this information to costs. The most commonly known
and widely used Casemix system is the Diagnosis Related Groups Casemix system
(DRGs), a system that groups hospital inpatients primarily based on routinely
collected patient variables, such as demographic, diagnostic and therapeutic
characteristics[5]. The World Health Organization (WHO) Family of
International Classifications[6] has been developing into an array of
interlinked domain classifications since its introduction in 2001[7]. The interconnections provide a base for a
rethinking and refinement of Casemix structures. Building upon the success of
DRGs, several Casemix systems have been developed [8]. The development of Casemix in rehabilitation
poses similar challenges for healthcare systems all around the world. Casemix
tools must capture all the key cost-determinants of treatment for patients with
complex needs[9]. Casemix models for funding and outcome analysis of
healthcare rely on accurate and complete data to classify the complexity and
costliness of the care required[10]. Casemix
systems improves predictive ability and fosters homogeneity in Casemix groups about
costs and length of stay. Collection and integration of functioning information
varied across studies. Results suggest that, in particular, DRG Casemix systems
can be improved in predicting resource use and capturing outcomes for frail
elderly or severely functioning-impaired patients [11]. Implementation of Casemix system needs a
well-organized and computerized system with well-trained and oriented staff [12]. The International Centre for Casemix and
Clinical Coding (ITCC) in National University of Malaysia, considering its
experience and technical capacity to conduct training in this field, proposed
to establish a universal case-mix education programs, especially for developing
country, through providing an e-learning program (ELP) for Casemix and clinical
coding and evaluate its success [13].The ITCC can provide accessible, affordable,
continuous and high quality training program for capacity building in Casemix
system to support implementation of case-mix system in developing countries [14]. Universiti Kebangsaan Malaysia Medical Center
(UKMMC) is one of Malaysia's leading hospitals that adopted the case-mix system
in 2002. This system was implemented as a suitable provider payment mechanism,
aligning with the ongoing national health reform efforts to deliver equitable
and efficient health services[15].In 2010, the Ministry of Health (MOH)
introduced the Malaysian DRG casemix system and progressively rolled it out
across the entire country [16], [17]. In 2005, the Indonesian government chose to
adopt casemix as a provider payment mechanism. Initially implemented as a pilot
project in 15 selected government hospitals, it was later expanded to include
all government hospitals across Indonesia by 2008. In 2010,
the casemix Indonesian Diagnosis Related Groups (INA-DRG) system was
introduced, and later that year, the Ministry of Health implemented a more
comprehensive casemix system known as Indonesia Case Base Groups (INACBG),
following a formal decree[18]. Hospital staff play an essential role in the
hospital for developing and maintaining the health information system (HIS).
They also play significant roles in ensuring the success of Casemix system
implementation. Casemix system consists of four main components that need to be
simultaneously implemented. One of them is Information technology (IT)
components involving adopting and maintaining the software and linking it with
the current system. Without proper knowledge on Casemix system, they cannot
adequately support the Casemix implementation. Thus, the implementation will
face a major problem and cannot be sustained in the long term. Researchers
found that by increasing understanding of the funding system and health systems
and improving knowledge among staff and managers in Social Security Organization (SSO), these can help in providing the groundwork
for service improvements. The level of knowledge about funding system as well
as the need for education, not only about Casemix, but about the funding
mechanisms in general can be revealed using a simple questionnaire [19]. Adequate knowledge, good attitude, and perception towards Casemix
system is important to implement and maintain the system. There was no study done before regarding
Knowledge, Attitude, and Perception towards Casemix system among the hospital
staff in Malaysia and Indonesia. The aim of the study was to evaluate the
knowledge, attitudes, and perceptions of the Casemix system among hospital
staff in selected hospitals in developing countries, with a focus on Malaysia
and Indonesia.
Material and Methods
Study design and sampling
A cross-sectional study was conducted among
hospitals staffs in Malaysia and Indonesia. We calculated the sample size for this study using a
95% confidence level, a 70% proportion[19] of hospital staff meeting the selection criteria, and
a 5% margin of error. Based on these parameters, the minimum required sample
size was determined to be 323. We had chosen purposively thirty-six (36)
hospitals in total from Malaysia and Indonesia to assess their HIS. These
hospitals were selected according to the convenient of the researcher. The
chosen hospitals were inter-related with the hospital staffs who answered the KAP
questionnaire.
Study questionnaire
A questionnaire was used for data collection.
The questionnaire was developed from inception, as it was a novel questionnaire
designed specifically to test participants’ knowledge, attitude, and perception
on various level of Casemix implementation. There are four sections in this
questionnaire that include data on basic respondents' socio-demographic
profile, knowledge, attitude, and perception. In addition to collecting
socio-demographic profiles of the participants, questions were also asked about
their years of experience, type of occupation, type of hospital, and attendance
at Casemix workshops. Years of experience in Casemix were categorized as
follows: less than one year was considered low experience, while more than one
year was classified as high experience. Occupations were categorized into
officer and operational staff; officers include IT officers, Programmers,
Doctors, or any personnel in the hospital’s IT department who hold a bachelor's
degree, the operational staffs are referred to support staff that working in
the IT department who hold a diploma. Hospitals in Indonesia were classified
into four categories: Class A: General hospitals with extensive facilities and
broad capabilities in both medical and subspecialty services. Class B: Public
hospitals with medical facilities and at least 11 limited specialists and
subspecialists. Class C: Public hospitals offering essential specialist medical
services. Class D: General hospitals with basic medical facilities and skills [16].
The experts designed
the questionnaire with a 5-point Likert scale (1 to 5) response options. These options were: highly agree (coded as
5), agree (4), unsure (3), disagree (2) and highly disagree (1). These were
later reclassified into two categories; "False" (which include
answers that are "Unsure, Disagree and Highly Disagree") answers and
"True" (which include answers that are "Highly Agree and
Agree") answers for knowledge. There were twelve (12) questions on
respondents' attitude; on costing, tariff, and the grouper, which assessed the
respondents' response towards Casemix during the working tenure and their
attitude to implementing it. The options
were: Highly Agree (coded as 5), Agree (4), Unsure (3), Disagree (2) and Highly
Disagree (1). There were no right or wrong answers on their attitude-wise as
these were how they perceived their own experiences. The last section consisted
of ten (10) questions on the perception of respondents on Casemix
implementation. These were reclassified into three classes; highly agree and
agree were combined into agree, disagree, and highly disagree were combined
into disagree, and the last option was "unsure".
Cut-off points
Knowledge was categorized into three groups
which are High Knowledge (score 8 to 10), Moderate Knowledge (score 5 to 7),
and Low Knowledge (score 0 to 4).
The total score was 60-point based on the answers
given by the respondents and were categorized into three (3) groups; Positive
Attitude (score = 47 to 60), Neutral Attitude (score = 41 to 46) and Negative
Attitude (score = 12 to 40). Perception was categorized into three groups which
are High Perception (score 16 to 20), Medium Perception (score 8 to 15), and
Low Perception (score 0 to 7).
Validation
All questions were designed by experts in the
field and further validated by face validation and internal consistency. The
Alpha Cronbach reliability analysis showed an acceptable alpha value of 0.722
for ten (10) items on knowledge, 0.802 for twelve (12) items on attitude, and
0.710 for ten (10) items on perception.
Statistical analysis
The data was analysed using the Social Sciences
Statistical Package (SPSS) version 26 computer software programme. Descriptive
and inferential statistics were used such as frequency tables, graphs, standard
deviations, percentages, bivariate (Chi-square test), and multiple regression
analysis.
Ethical Clearance
This study was approved by the Universiti
Kebangsaan Malaysia (UKM) Research and Ethics Committee. Participants were
supplied with information about the research. They also had been briefed
through verbal and written descriptions and explanations, about their position
in the study and their rights as participants. Those who decided to participate
acknowledged their consent was aware and voluntary, not due to misinformation
or coercion from the researcher.
Results:
A total of five hundred and fifty (550)
self-administered questionnaires were distributed among the hospital staffs and
three hundred and fifty (350) questionnaires were completed and returned giving
the response rate of 63.6%. Most of the respondents were from Indonesia (58.6%)
and the rest were from Malaysia. Female respondents dominated the study at 60%.
The demographic result also showed that 64.0% from respondents were working as Operational
Staffs. The high percentage (86.6%) of the respondents who had never attended
any prior Casemix training. Among the participants, 75.1% from the respondents
were below than 40 years’ old. Most of the respondents had low experienced in Casemix
(72.6%). Respondents from type B hospitals dominated at 64.0%,
followed by type C hospitals (19.7%), type A hospital (14.0%), and type D
hospitals (2.3%) in the study (Table 1).
Table 1. Distribution of respondents by
socio-demographic characteristic
Factors |
N |
% |
|
Country |
Indonesia
|
205 |
58.6 |
Malaysia |
145 |
41.4 |
|
Gender |
Male |
140 |
40.0 |
Female |
210 |
60.0 |
|
Type of Occupation |
Officer |
126 |
36.0 |
Operational Staffs |
224 |
64.0 |
|
Attended Casemix Workshops |
Yes |
47 |
13.4 |
No |
303 |
86.6 |
|
Age Group |
Younger
(<40) |
263 |
75.1 |
Older (≥ 40) |
87 |
24.9 |
|
Experience in Casemix |
High Experience
(≥1) |
96 |
27.4 |
Low Experience (<1) |
254 |
72.6 |
|
Type of the study hospitals |
Type A |
49 |
14 |
Type B |
224 |
64 |
|
Type C |
69 |
19.7 |
|
Type D |
8 |
2.3 |
Knowledge on Casemix system of the respondents
showed that 39.7% of respondents had low knowledge, 58% of them had moderate
knowledge, while only 2.3% had high knowledge. The mean knowledge score for the
respondents was 4.84 out of the possible 10 points (SD=2.088). Factors such as
the location of the hospitals (p <0.0001), hospital types (p < 0.0001),
respondents that had attended the Casemix workshop (p=0.001), years of
experience of the respondents (p=0.000), and type of occupation of the
respondents (p=0.002) were significantly associated with the level of knowledge
(Table 2).
Table 2. Determination of factors associated
with knowledge level
Factors |
High Knowledge |
Moderate Knowledge |
Low Knowledge |
p |
||||
N |
% |
N |
% |
N |
% |
|||
Country |
Malaysia |
1 |
1 |
30 |
21 |
114 |
79 |
<0.0001 |
Indonesia |
7 |
3 |
173 |
85 |
25 |
12 |
||
Hospital Types |
A |
0 |
0 |
28 |
57 |
21 |
43 |
<
0.0001 |
B |
5 |
2 |
111 |
50 |
108 |
48 |
||
C |
2 |
3 |
57 |
83 |
10 |
14 |
||
D |
1 |
13 |
7 |
88 |
0 |
0 |
||
Attended Casemix Workshop |
Yes |
1 |
2 |
39 |
83 |
7 |
15 |
0.001 |
No |
7 |
2 |
164 |
54 |
132 |
44 |
||
Experience (Years) |
High Experience |
2 |
2 |
76 |
79 |
18 |
19 |
<0.0001 |
Low Experience |
6 |
2 |
127 |
50 |
121 |
48 |
||
Type of Occupation |
Officers |
4 |
4 |
64 |
70 |
23 |
25 |
0.002 |
Operational
Staffs |
4 |
2 |
139 |
54 |
116 |
45 |
||
Gender |
Male |
5 |
4 |
87 |
62 |
48 |
34 |
0.128 |
Female |
3 |
1 |
116 |
55 |
91 |
43 |
||
Age Group |
Younger
(<40) |
4 |
2 |
148 |
56 |
111 |
42 |
0.086 |
Older
(≥ 40) |
4 |
5 |
55 |
63 |
28 |
32 |
Study found that 90.0% of respondents have a
negative attitude towards Casemix. Only 0.6% of them have positive attitude
while the rest 9.4% of them have neutral attitude towards Casemix. The mean
attitude score for all respondents was 35.92 out of a possible 60 points (SD =
5.192). The range of attitude scores was 12 to 51 respectively. Bivariate
analysis was performed using Pearson Chi-square test to compare the attitude
scores with factors though to influence such as gender, country, hospital type,
attended Casemix workshop, age, experience, and types of occupation of the
respondents. Results shows that all factors were not statistically significant (p>
0.05) except age (p=0.034) associated with the attitude towards Casemix (Table
3).
Table 3. Determination of factors associated
with attitude
Factors |
Positive |
Neutral |
Negative |
p |
||||
N |
% |
N |
% |
N |
% |
|||
Country |
Malaysia |
1 |
1 |
12 |
8% |
132 |
91 |
0.672 |
Indonesia |
1 |
0 |
21 |
10 |
183 |
89 |
||
Hospital Types |
A |
0 |
0 |
3 |
6 |
46 |
94 |
0.827 |
B |
2 |
1 |
23 |
10 |
199 |
89 |
||
C |
0 |
0 |
7 |
10 |
62 |
90 |
||
D |
0 |
0 |
0 |
0 |
8 |
100 |
||
Attended Casemix Workshop |
Yes |
1 |
2 |
7 |
15 |
39 |
83 |
0.115 |
No |
1 |
0 |
26 |
9 |
276 |
91 |
||
Age Group |
Younger (<40) |
0 |
0 |
23 |
9 |
240 |
91 |
0.034 |
Older (≥ 40) |
2 |
2 |
10 |
12 |
75 |
86 |
||
Gender |
Male |
0 |
0 |
15 |
11 |
125 |
89 |
0.146 |
Female |
2 |
1 |
18 |
9 |
190 |
90 |
||
Experience (Years) |
More Experience |
1 |
1 |
14 |
15 |
81 |
84 |
0.095 |
Less Experience |
1 |
0 |
19 |
7 |
234 |
92 |
||
Type of Occupation |
Officers |
0 |
0 |
12 |
13 |
79 |
87 |
0.261 |
Operational Staffs |
2 |
1 |
21 |
8 |
236 |
91 |
The perception level, 11.4% of respondents
(n=40) has high perceptions towards Casemix; however, the majority at 84.9%
(n=297) has medium perception towards Casemix. The mean perception score for
all respondents were 12.07 out of a possible 20 points (SD = 2.67). The range
of perception score was 6 and 20, respectively. The perception scores were
tested with factors that influence gender, country, hospital type, attended Casemix
workshop, age, experience, and type of occupation of the respondents using
Pearson Chi-square test. Result shows that the only country factor was
significantly associated with the level of perception (p=0.009) in the study
(table 4).
Table 4. Determination of factor associated with
perception
Factors |
High
Perception |
Medium
Perception |
Low
Perception |
p |
||||
N |
% |
N |
% |
N |
% |
|||
Country |
Malaysia |
9 |
6 |
126 |
87 |
10 |
7 |
0.009 |
Indonesia |
31 |
15 |
171 |
83 |
3 |
1 |
||
Hospital Types |
A |
6 |
12 |
43 |
88 |
0 |
0 |
0.230 |
B |
23 |
10 |
191 |
85 |
10 |
4 |
||
C |
8 |
12 |
58 |
84 |
3 |
4 |
||
D |
3 |
38 |
5 |
63 |
0 |
0 |
||
Attended Casemix Workshop |
Yes |
6 |
13 |
39 |
83 |
2 |
4 |
0.928 |
No |
34 |
11 |
258 |
85 |
11 |
4 |
||
Age Group |
Younger (<40) |
28 |
13 |
186 |
83 |
10 |
4 |
0.157 |
Older (≥ 40) |
12 |
10 |
111 |
88 |
3 |
2 |
||
Gender |
Male |
19 |
14 |
116 |
83 |
5 |
4 |
0.589 |
Female |
21 |
10 |
181 |
86 |
8 |
4 |
||
Experience (Years) |
More Experience |
15 |
16 |
79 |
82 |
2 |
2 |
0.213 |
Less Experience |
25 |
10 |
218 |
86 |
11 |
4 |
||
Type of Occupation |
Officer |
11 |
12 |
79 |
87 |
1 |
1 |
0.306 |
Operational Staff |
29 |
11 |
218 |
84 |
12 |
5 |
Discussion
The findings revealed a generally low level of
knowledge among the respondents, primarily due to their limited experience with
Casemix and the high number who had not attended Casemix training. Similar
results have been reported in other studies[19]–[23]. The findings indicate that operational staff
have less knowledge compared to officers. This aligns with a study in Australia
[24]. Participants who attended a Casemix workshop
demonstrated better knowledge compared to those who did not attend. This
finding is consistent with another study[25], which reported that individuals who
participated in workshops or training programs on the DRG system had greater
knowledge than those who did not attend. Many studies demonstrated that
participating any training course or workshop can help to increase knowledge.
Training helps employees gain a clearer understanding of their responsibilities
and equips them with the necessary knowledge and skills to perform their job
effectively. Indonesia participants had better knowledge than Malaysian
participants it may due to Since January 1, 2014, the Indonesian government has
implemented the National Health Insurance program, known as National Health
Insurance Scheme (JKN), with the aim of achieving Universal Health Coverage in
Indonesia. By 2019, JKN covered 72% of the country's population. This shift in
the health service system presents both opportunities and challenges for
hospitals. Additionally, the tariff structure for healthcare services has been
updated to the INA-CBGs packages, a unique case-mix model tailored for
Indonesia[26]. Knowledge levels differed significantly among
participants based on hospital type, work experience, and their roles as
officers or operational staff. This variation may be due to forgetfulness, a
lack of perceived value in the behavior, and potentially inadequate educational
materials on the Casemix System. The majority of participants in this study had
a negative attitude toward Casemix. The findings suggest that the participants'
level of knowledge directly influences their attitudes. The knowledge level of
the participants was low. Another possible reason for this is that various
other factors may impede the process; behavior is influenced not only by
attitude and knowledge but also by motivation, perceived benefits, social
factors, and other elements. It’s also possible that these individuals do not
fully appreciate the significance of their role in Casemix implementation. Some
may believe that Casemix will simply increase their workload without providing
any tangible benefits. Indonesian participants had a more positive perception
of Casemix than Malaysian participants. This is maybe because of Indonesia hospital’s
staff get more access to a training programme as part of their development
programme and the system has implemented in whole nations. To successfully
implement the Casemix system, training providers or the government could
consider subsidizing training fees to encourage participation. The study has
several limitations. Due to constraints of time and resources, it was conducted
solely in selected hospitals in Malaysia and Indonesia, which may not represent
all developing countries or the entire staff population in these nations.
Future research should encompass a broader range of developing countries,
include more hospitals, and involve a larger number of participants.
Conclusion
Most of participants demonstrated a low level of
knowledge about Casemix and expressed a negative view towards Casemix.
Regarding perceptions, a minority had a high perception of Casemix, while most
had a medium perception. To successfully implement the Casemix system, it is
crucial to address the low level of staff knowledge and gain their support.
This can be achieved by using an effective system integrated with existing
processes.
Acknowledgment
We would like to thank all the respondents in the respective hospitals that participated in this study.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of
interest
Funding: no funding.
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