Physicians' and Hospital Administrators' Perspectives of Diagnosis-Related Groups (DRGs) in High-Income Countries: A Systematic Review.

Abstract

Background: Diagnosis-related groups (DRGs) are among the most widely adopted case-mix-based hospital payment systems, introduced to improve efficiency, enhance cost transparency and contain rising healthcare expenditure. Although a substantial body of literature evaluates the economic and system-level effects of DRGs, comparatively less attention has been paid to the perspectives of healthcare providers who work within these reimbursement structures and directly experience their consequences in daily clinical practice.

Objective: This systematic review synthesises evidence on physicians' and hospital administrators' perspectives of DRG-based payment systems in high-income countries, with particular attention to perceived effects on clinical decision-making, quality of care, administrative workload and professional autonomy. Nursing and allied health perspectives are identified as warranting a separate dedicated review and are not the focus of the present work.

Methods: The review was conducted in accordance with PRISMA 2020 guidelines and registered with PROSPERO (CRD42024575025). Six electronic databases (PubMed, Scopus, Web of Science, CINAHL, Embase and ProQuest) were searched for English-language studies published between 1994 and 2024. Qualitative, quantitative and mixed-methods studies reporting provider or hospital-level perspectives on DRG implementation were included. Methodological quality was assessed using the Joanna Briggs Institute (JBI) appraisal tools and risk of bias was assessed using the ROBINS-I tool. The Mixed Methods Appraisal Tool (MMAT) was available for mixed-methods studies, though none were ultimately included. Findings were synthesised narratively using thematic aggregation.

Results: Twelve studies from approximately 25 high-income countries met the inclusion criteria. Healthcare providers acknowledged several benefits of DRG systems, including improved cost transparency, more standardised care pathways and incentives for efficiency. However, concerns were consistently raised regarding increased administrative workload, reduced clinical autonomy, financial pressure to shorten length of stay and potential risks to care quality, particularly for complex or severely ill patients. Provider acceptance of DRGs varied substantially across settings and was strongly influenced by local system design, training, coding infrastructure and alignment with professional values.

Conclusion: From the perspective of physicians and hospital administrators, DRG-based payment systems represent a trade-off between economic rationalisation and clinical discretion. Although DRGs can support efficiency and accountability, their success depends critically on thoughtful system design, adequate training, robust data infrastructure and ongoing engagement with providers to safeguard care quality and professional autonomy. Nursing and allied health perspectives, which the available evidence base did not allow this review to address adequately, represent an important and underexplored dimension of provider experience with DRG systems and warrant focused future research.