DOI Number: 10.5958/0976-5506.2019.01703.

Analysis of Typhoid Fever Clinical Pathway Implementation in

the Era of National Health Insurance in Indonesia

Widia Puspa Hapsari1, Atik Nurwahyuni1

1
Department of Health Administration and Policy, Faculty of Public Health, Universitas Indonesia,
Depok, Indonesia

ABSTRACT
Starting in November 2016, pricing policy for private hospital in Indonesia was specifically set in a fixed
tariff called INA-CBGs (Indonesian Case Base Groups). PMI Hospital which was affected by INA-CBGs
regulation built Clinical Pathway for Typhoid fever in order to cope with the challenge. It admitted 705 cases
in less than a year in 2016 yet it was claimed that the reimbursement for each case was still lower than the
hospital cost. Study aimed to explore variation of medical practices based on Clinical Pathway considering
INA-CBGs 2016 pricing policy. Cases included in the study were 156 cases with homogenous severity
level chosen from October 2016 to March 2017. Historical data was taken from hospital information system
including medical record and billing details. Data was processed using ClinPath V.2.0 tools developed by
Faculty of Public Health Universitas Indonesia resulting in distribution of variation. Variation resulted in
Length of Stay was (4.27 days) and it was expected to be 4-5 days in clinical pathway while not all patients
utilized the same procedure within one period of care. There were also non-value added diagnosis such
as Complete Urine (0.01) and Electrolyte test (0.01) included. Consumption of antibiotic (0.28) which
consisted of 25 different trade names from different structures resulted in various tariff of services. Variation
drives medical cost resulted in tariff increment. Typhidot test can be taken into consideration and the use of
later generation of antibiotics are recommended considering affordability and availability.

Keywords: Clinical Pathway, Medical Practice, Compliance, Typhoid Fever, Variation

Introduction
Shifting system from fee for services to Case Base
Groups had given new insight for hospitals to be more
efficient in spending their resources without putting aside
their service quality1. Started in 2016, tariff for private
hospital for each case group was set in fixed amount and
was prospectively reimbursed by BPJS (Independent
pooling organization for national health insurance)2.
PMI (Indonesian Red Cross) Hospital is a type B private
hospital with 264 beds as a referral hospital for inpatient
care in local area3. During the enactment of INA-CBGs
2016 pricing policy, hospital claimed that reimbursement
Corresponding Author:
Atik Nurwahyuni
Department of Health Administration and Policy,
Faculty of Public Health, Universitas Indonesia,
Depok, Indonesia
Email: atikn.akk@gmail.com
offered by BPJS (third party payer) was quite lower than
the cost made by the hospital.
Typhoid fever frequently happened in Bogor area
(where PMI hospital is located). In 2016, there were 18.797
cases of Typhoid fever in Bogor and it was distributed
among various age groups4. It was recorded that Typhoid
fever cases in PMI hospital alone was 705 admissions
in less than a year3. Those numbers showed that PMI
hospital had both the opportunity as well as the challenge
to manage its resources in a more efficient way. In order
to answer the challenge, PMI hospital has established
their own Clinical Pathway for Typhoid fever. Length of
Stay for homogenous cases of Typhoid fever were found
to be 1 up to 6 days. Studies in several countries showed
that prospective payment system (e.g. INA-CBGs) would
affect Length of Stay, type of services and consequently
the medical cost5–8. Implementation of INA-CBGs pricing
policy supported with clinical pathway was expected
to reduce non-value added activities yet variation still
existed. Thus, a more in depth analysis needed to be
conducted to elaborate which medical practices induced
more variation to the service.
 966 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7

Method doctor’s approvals. Hospitals provided patients with their

accommodation of choice. Fifty three patients chose to
This study took place at PMI Hospital located utilize class I, 27 patients chose class II, 34 patients chose
in Bogor, West Java. This study used quantitative VIP class, and lastly 19 patients preferred VVIP class
approach to identify variation in medical practices and (See Table 1). Various medical services were used in
was elaborated using descriptive statistics. Distribution treating patients with Typhoid fever. Doctor visits were
of patients’ characteristics included age, sex, payment given 4 times (once per day) in clinical pathway while
methods (JKN/National Health Insurance, Private only 0.39 of the services was practically performed by
Insurance, Out of Pocket), and inpatient accommodation the Internists during the stays. Average tariff of doctor
(class I, II, III, VIP, VVIP). Data for identifying Length visits was IDR 94.739. The data shows that average
of Stay were also taken from the duration between utilization of consultation was 0.02 and average tariff for
admissions to the discharge date. Data taken from each consultation was IDR 79,839. Complete blood test
medical record was then recapitulated and digitized was utilized 0.06 times (IDR 78,537).
by medical record unit. Another set of data were taken
from billing unit, for example billing details. Medical
and medical supporting services details were then Table 1: Characteristics of Patients with Typhoid
classified as Laboratory, Consultation, Doctor Visits, Fever
and Procedure. Drugs were also classified using ISO Items Cases
(Informasi Spesialite Obat) for its therapeutic functions.
Number of Cases (N) 156
Fragmented data were connected using registration
LOS (Days)
number. Data selection resulted in 156 homogenous cases
with the same severity level (without any complication ALOS 4.27
and comorbidity). Data was processed using a public Minimum 3
domain software ClinPath V.2.0 built by Universitas Maximum 6
Indonesia. Variation showed in LOS, Average utilization Age (Years of Age)
of medical and medical supporting services, and various
Average 24
medical consumption of drugs, and average tariff for
services then be compared to hospital clinical pathway. Minimum 1
Maximum 82
Results Sex (%)
Male 45.51
Since its initial implementation, Typhoid fever
Female 54.49
clinical pathway has not been evaluated. According to
the hospital internal consensus, Length of Stay (LOS) Payment Methods (N)
for Typhoid fever was 4-5 days and patients were JKN 74
planned to be discharged with doctors’ approval. Several Private Insurance 19
medical activities e.g. anamnesis, physical assessment, Out of Pocket 37
diagnostic examinations, procedures, monitoring up
Hospital Staff 1
to discharge planning were supposed to be conducted
within LOS. Other 25
Discharge Status (N)
Average Length of Stay for homogenous cases was With Approval 151
4.27 days with maximum stays up to 6 days and the
Against Advice 5
least stays were 3 days. Vast majority of patients paid
services using Indonesian National Health Insurance/ Type of Accommodation
JKN (74 patients), 37 patients paid out of pocket, and I 53
19 patients paid via Private Health Insurance, they were II 27
mostly workers and were insured by the companies’ III 34
third party payers e.g Admedika, Inhealth, Antam, Sinar
VIP 23
Mas, Sampoerna. Five patients were discharged against
advice and the rest of 151 patients were discharged with VVIP 19
 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7 967

Complete urine test (0.01) and Electrolyte (0.01) Table 3: Average Consumption of Drugs Based on
tests were also conducted and average tariff for both Clinical pathway
services were each IDR 45,969 and IDR 319,000.
Clinical Clinical
Medical Procedures e.g. Crystalloid IVFD average Drugs
Pathway Practice
utilization was 0.04 while it must be done every day (4
During stays
times during stays), each service was worth IDR 161,333.
Quinolone + -
Nursing care was given with average utilization of 0.39
(4 times in clinical pathway). Nursing care included Cephalosporin + -
monitoring body temperature, nutrition intake, and PPI + +
personal hygiene. The service average tariff was IDR Discharge Planning
56,669. Tariff for Injection was IDR 49,493 and was Chloramphenicol Oral + -
given 0.37 times during 1 period of care (See Table 2). Cephalosporin Oral + -
PPI + +
Table 2: Average Utilization in Medical and Medical Note: + Drugs recommended by hospital CP or utilized
Supporting Services in clinical practice, - not utilized in clinical practice
Hospital Drugs used for discharge planning were consumed
Clinical Clinical
Items Tariff starting on the last day of stays up to consecutive
Pathway Practice
(IDR)
days after discharge (See Table 3). Variation included
Visits by Specialist 4 0.39 94,739 antibiotics classified not only in quinolone (with 4
Consultation - 0.02 79,839 variation in trade names) and cephalosporin (25 different
Diagnostic trade names), but also from other lines and generations.
Examination
Complete Blood Table 4: Average Consumption of Drugs
1 0.06 78,573
Test
Widal/tubex 1 - - Drugs Therapeutic Clinical Medical
IgM Salmonella - 0.02 251,304 Classification Pathway Practice
SGOT - 0.02 48,000 Adsorbents - 0.33
SGPT - 0.02 47,677 Analgesic - 1.11
Complete Urine Analgesic Opioid - 0.03
- 0.01 45,969 Anti-Dysrhythmia - 0.01
Test
Electrolyte (Na, K, Anti-Histamine - 0.74
- 0.01 319,000
Cl) Anti-Hypertensive - 0.05
Medical Procedure Anti-Inflammatory - 0.30
Crystalloid IVFD 4 0.04 161,333 Anti-Platelet - 0.01
Oxygen *4 - - Anti-Spasmodic - 0.07
Electrocardiogram - 0.01 57,955 Antibiotic - 0.72
Nursing Care 4 0.39 56,669 Antibiotic (Skin & respiratory
- 0.49
Injection - 0.37 49,493 Infection)
Note: (*) Not necessarily mandatory. Tariff was counted Antiemetic - 0.80
using 2016 value of money (1 USD=IDR 13,519) Antipyretic - 0.06
Antithyroid - 0.32
Recommended antibiotics in hospital clinical
Bronchodilator - 0.19
pathway were mostly broad spectrum (Quinolone and
Digestive system - 0.14
Cephalosporin) (see Table 3) although, these were not
Laxative - 0.01
used in medical practices. Hospital also suggested using
Proton Pump Inhibitor (PPI) and practically used was Probiotic - 0.53
Omeprazole with different types of brands (0.30). Vitamin - 0.06
 968 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
Conted…
Anti-Depressant - 0.13
Vasoconstrictor - 0.05
Adenoreceptor - 0.08
Relaxant - 0.03
Diuretic - 0.02
Vasodilator - 0.03
Decongestant - 0.01
Anti-Diabetic - 0.01
Compounding Medicine - <0.01
Several drugs were also given to the patients with
typhoid fever e.g. Adsorbent classified drugs (0.33
tablet). There were also two kinds of painkiller used
in practice, Analgesic (1.11) and Opioid Compound
(0.03). Anti-Hypertensive e.g. Amlodipine (0.05), Anti-
Inflammatory such as Triamcolone and Dexamethasone
(0,3 tablet), Anti-Platelet in the form of Clopidogrel
(0.01), Anti-Spasmodic as in Otilonium Bromide and
Hyoscine Butylbromide (0.07). Other therapeutic drugs
were also consumed as shown (See Table 4).
Discussion
Typhoid fever can be detected by using
microbiological procedure, serological procedure
and other examination e.g. PCR test9. PMI Hospital
suggested widal test for diagnosing Typhoid fever on the
first day of patient’s admission. This test only results on
moderate sensitivity and specificity and can only be done
on day 6-12 for specific antibody O or H and might show
negative result up to 30.0% of proven culture10. Typhidot
IgM however has 75.0% of sensitivity and 60.7% of
specificity which made it more accurate in diagnosing
Typhoid fever than widal test did11. Average tariff for
Typhidot IgM in PMI Hospital was IDR 251.304, higher
than the tariff for Widal test in hospitals in the nearby
area, which were IDR 55.000 for private hospital and
IDR 52.000 for public regional hospital12,13. Despite the
higher tariff for Typhidot IgM test, hospital took the test
accuracy into consideration.
Diagnosis tests out of hospital clinical pathway
e.g. SGOT/ SGPT became ineffective because patients
with Typhoid fever subsequently experienced clinical
sign in which their level of enzymes increased due to
endotoxicity, immune mechanism, and the consumption
of drugs9. Complete urine test is commonly used to
detect excessive substances in blood excreted in the
urine and infection related to urinary tract infections14–16
Salmonella typhi can be detected through urine culture
for its Vi antigen and be best detected using PCR method
without any bacteriological changes interference17,18.
Nonetheless, high tariff for PCR test was still one of the
considerations.
Mostly used quinolone was Levofloxacin 500 mg
(IDR 1,500) because it was more affordable than other
quinolone such as Levofloxacin IV Fluids (IDR 105,600)
or Lexa IV fluids 750 mg (IDR 422,400). Ciprofloxacin
used by hospital had the lowest tariff (IDR 867) known
for more severe adverse effect including nausea, nerve
damage, and further myasthenia gravis19. Clinical
Pathway recommended patients with Typhoid fever to
be given antibiotic per day of stay. However, average
consumption of 25 different Cephalosporin (antibiotics)
varied. Average tariff also varied from IDR 1,573 up to
IDR 369,930. Frequently consumed antibiotics was 1 gm
of Ceftriaxone given via injection (IDR 18,700). Each
gram of Ceftriaxone injection can be used for both adult
or pediatric patients9. As study resulted that the youngest
patient suffered from Typhoid fever was a 1-year-old
and the oldest was a 82-year-old. Ceftriaxone is also
more active against gram negative bacteria and less
active against positive bacteria20. Thus, ceftriaxone was
mostly used (average utilization 4.61) to treat patients
with Typhoid rather than other Cephalosporin drugs.
However, Ciprofloxacin (belongs to Fluoroquinolone)
had higher rate of Salmonella infection eradication than
Chloramphenicol (90% compared to 89%)21.
Consumption of PPI drugs was not necessarily
needed unless there were adverse effect e.g. intestinal
injury of a non-steroidal anti-inflammatory drugs
(NSAIDs)20. On that account, average consumption of
PPI drugs was only 0.30. Other therapeutic drugs namely
Adsorbent containing Loperamide HCL (0.33) was used
to control acute non-specific diarrhea associated with
inflammatory bowel disease which often happens to
patient with Typhoid. There were 3 types of laxatives
used which worked differently. Dulcolax containing
bisacodyl (average utilization 0.02) works in stimulating
mucosal sensory nerves, consequently increasing
peristaltic contraction of colon20. Mycrolax cointaining
Sucrose (average utilization 0.02) works in creating
bulk and increasing amount of water in the system, and
Lactulax, a non-absorbable sugar/disaccharide (0.01)
 Indian Journal of Public Health Research & Development, July 2019, Vol.10, No. 7
used to treat constipation by pulling water out into colon
also to reduce ammonia in blood to treat liver disease20.
Lactulax was the most expensive laxative (IDR 125,400)
among the other two Mycrolax (IDR 24,063) and
Dulcolax (1,580).
Commonly used analgesic was paracetamol (7,42)
with average tariff (IDR 205) per tablet. It was used
to reduce temperature which followed Salmonella
infection. Anti-inflammatory was also used in 17
different trade names. The most consumed Anti-
inflammatory was Triamcolone (0.78) which worked
by suppressing inflammation due to enteric infection.
Antiemetic was also consumed by patients with Typhoid
fever. There were 14 trade names consisted of mostly
Ondansentron worked by blocking serotonin receptor
resulting in suppression of nausea and vomiting22.
Other drugs which has no direct effect to Typhoid fever
treatment were also given to patient.
Conclusion
Variation persistently happened despite the enactment
of INA-CBGs 2016 Pricing Policy. Variation happened
in medical supporting service (laboratory). Typhidot
was the most proper test used to support Typhoid fever
diagnosis in patients considering affordable tariff and
availability of resources. Consumption of both various
kind of therapeutic drugs and trade names including
various antibiotics and other unnecessary drugs such
as anti-depressant, Bronchodilator, Vasodilator, etc.
was considered a non-value added activity. These
induced additional costs which resulted in tariff
increment. Hospital might suffer financial loss due to
disproportionate fixed reimbursement set in INA-CBGS
2016 Pricing Policy. This can be averted by regularly
evaluating clinical pathway based on medical practice
and increase professionals’ concordance in delivering
services for typhoid fever.
Acknowledgement
The authors acknowledge both Faculty of Public
Health and Directorate of Research and Community
Engagement Universitas Indonesia for supporting the
study and publication processes.
Conflict of Interest: The authors state that there are no
conflict of interests included in the study.
969
Source of Funding: Study was funded by Directorate
of Research and Community Empowerment Universitas
Indonesia (DRPM UI) through International Indexed
Publication and Students’ Thesis Grant (Hibah PITTA
2018) on 2180/UN2.R3.1/HKP.05.00/2018 agreement
number.
Ethical Clearance: This research has already passed
ethical clearance done by Faculty of Public Health
Universitas Indonesia Ethical Committee with reference
number 671/UNF.F10/PPM.00.02/2018.
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