EVALUASI KESESUAIAN DIAGNOSIS RUJUKAN DI FASILITAS KESEHATAN PRIMER DAN RUMAH SAKIT PADA INDIKATOR RASIO RUJUKAN NON SPESIALISTIK (RRNS)

Sari Quratul'ainy, Dr.drg. Julita Hendrartini, M.Kes, AAK

2026 | Tesis | MAGISTER KEBIJAKAN DAN MANAJEMEN KESEHATAN

Latar Belakang: Rasio Rujukan Non-Spesialistik (RRNS) digunakan sebagai salah satu indikator kinerja Fasilitas Kesehatan Tingkat Pertama (FKTP) dalam sistem pembiayaan Kapitasi Berbasis Kinerja (KBK) Program JKN. Namun, perbedaan antara diagnosis ditegakkan di FKTP dan diagnosis di RS menimbulkan pertanyaan mengenai validitas RRNS sebagai cerminan mutu layanan. Penelitian ini bertujuan mengevaluasi kesesuaian diagnosis rujukan FKTP–RS serta mengidentifikasi faktor-faktor yang memengaruhi ketidaksesuaian diagnosis tersebut.

Metode: Penelitian ini merupakan studi potong lintang retrospektif menggunakan data klaim JKN sebanyak 315.488 kasus rujukan pada 86 FKTP dan 29 RS. Kesesuaian diagnosis ditentukan berdasarkan kecocokan klasifikasi diagnosis (spesialistik atau non-spesialistik) rujukan FKTP dengan diagnosis di RS. Variabel independen meliputi karakteristik FKTP, karakteristik pasien, karakteristik rumah sakit, serta kategori diagnosis dominan. Analisis dilakukan menggunakan regresi logistik binomial bivariat dan multivariat.

Hasil: Ketidaksesuaian klasifikasi diagnosis spesialistik dan non-spesialistik berhubungan signifikan dengan kapasitas FKTP, usia pasien, jarak ke rumah sakit rujukan, status PRB dan Prolanis, kelas rumah sakit, serta pada kategori diagnosis (CMG) tertentu. Ketersediaan laboratorium bersifat protektif terhadap ketidaksesuaian diagnosis. Meskipun kasus ketidaksesuaian lebih banyak terjadi di Klinik Pratama, dampak finansial KBK lebih besar pada Puskesmas.

Kesimpulan: Ketidaksesuaian diagnosis rujukan antara FKTP dan RS dipengaruhi oleh faktor kapasitas FKTP, karakteristik pasien, akses geografis, kesinambungan layanan penyakit kronis, kebijakan sistem rujukan serta rujukan pada kode CMG tertentu.Temuan ini menunjukkan bahwa RRNS memiliki keterbatasan sebagai indikator kinerja apabila diterapkan tanpa evaluasi berbasis risiko dalam konteks layanan primer, sehingga diperlukan penguatan kapasitas FKTP, optimalisasi PRB dan Prolanis, serta penyesuaian evaluasi RRNS.

 

Background: The Non-Specialistic Referral Ratio (NSRR) is used as a performance indicator for Primary Health Care Facilities (PHCFs) within the Performance-Based Capitation (PBC) scheme of Indonesia’s National Health Insurance (JKN). However, discrepancies between diagnoses established at PHCFs and those confirmed at referral hospitals raise concerns regarding the validity of NSRR as a measure of service quality. This study aimed to evaluate diagnostic concordance between PHCFs and hospitals and to identify factors associated with diagnostic discordance.

Methods: This retrospective cross-sectional study analyzed 315,488 JKN referral claims from 86 PHCFs and 29 hospitals. Diagnostic concordance was defined as agreement in diagnosis classification (specialistic vs. non-specialistic) between PHCF referrals and hospital diagnoses. Independent variables included PHCF characteristics, patient characteristics, hospital characteristics, and dominant diagnosis categories. Bivariate and multivariate binomial logistic regression analyses were performed.

Results: Diagnostic discordance was significantly associated with PHCF capacity, patient age, distance to referral hospitals, PRB and Prolanis status, hospital class, and specific Case-Mix Group (CMG) diagnosis categories. The availability of laboratory services at PHCFs showed a protective effect against diagnostic discordance. Although discordant cases were more frequent in primary clinics, the financial impact of PBC adjustments was greater in public health centers.

Conclusion: Diagnostic discordance between PHCFs and hospitals is influenced by PHCF capacity, patient characteristics, geographic access, continuity of chronic care services, referral system policies and spesific Case-Mix Group diagnosis categories. These findings indicate that NSRR has limitations as a performance indicator when applied without risk- and context-based evaluation, highlighting the need to strengthen PHCF capacity, optimize PRB and Prolanis programs, and refine NSRR assessment within the PBC framework.

Kata Kunci : Kesesuaian diagnosis, Rasio Rujukan Non-Spesialistik, RRNS, Kapitasi Berbasis Kinerja, KBK, Sistem Rujukan, JKN, Diagnostic concordance; Non-Specialistic Referral Ratio; Performance-Based Capitation; National Health Insurance (JKN).