진료의뢰센터를 경유한 환자들의 의료이용

Abstract

[한글]

이 연구는 진료의뢰센터를 경유한 환자군(이하 의뢰군)과 그 외의 경로를 경유한 환자군(이하 일반군)의 의료이용특성을 비교하고 질병을 보정한 재원일수 환자구성지표(case-mix index, 이하 CMI)를 분석한 후, 2차 분석으로 의뢰군의 다빈도 10대 주진단 환자와 일반군 환자를 1:1 짝짓기하여 치료결과를 분석하여, 진료의뢰센터의 운영을 파악하고자 하였다. 연구 자료는 2003년 신규 입원환자 9,484건을 사용하였고, 분석은 SAS (Statistical Analysis System) version 8.01판을 사용하였다.

주요 결과는 다음과 같다.

1. 전체 환자를 대상으로 의뢰군과 일반군의 의료이용특성을 비교하였는데, 인구사회학적 특성에서 직업은 사무ㆍ서비스직, 농업ㆍ임업유사직, 가정주부가 의뢰군 비율이 유의하게 높았으며, 거주지역은 서울ㆍ인근경기도, 경상ㆍ전라ㆍ제주도가 의뢰군 비율이 높았다.

2. 진료정보관련 특성에서, 질병을 보정한 재원일수 CMI로 분석한 결과, 의뢰군이 0.94, 일반군이 1.01로 의뢰군의 재원일수 CMI가 짧았으며, 평균 재원일수도 의뢰군이 7.5일로 일반군에 비하여 0.6일 짧았다. 퇴원과는 내과와 외과계의 경우, 기타진단이 있는 경우, 협진을 시행한 경우, 전과를 한 경우, 수술을 시행한 경우, 일반검사를 시행한 경우에서 의뢰군 비율이 높았다.

3. 질병정보관련 특성에서 한국표준사인분류 4차 개정판의 21대분류에 의한 주진단 분포를 비교하였는데, 신생물은 두 군 모두 가장 높은 분포를 보였으며, 의뢰군에서 가장 높은 분포를 보인 질환군은 신생물, 순환기계통의 질환이었다.

4. 의뢰군을 의뢰병원에 따라 협진병ㆍ의원, 협력병원, 그 외병원으로 나누어 세 그룹으로 구분한 후 진료정보관련 특성을 비교한 결과, 협력병원에서 의뢰된 경우가 협진병ㆍ의원에 비해 재원일수가 길고, 협진이 많았으며, 일반검사, 특수검사ㆍ처치를 더 많이 시행하였다.

5. 질병을 보정한 재원일수 CMI에 영향을 미치는 요인에 대한 다중 회귀분석결과, 직업은 기준군인 전문기술직에 비해 기타 직업이, 거주지역은 기준군인 서울ㆍ인근경기도에 비해 경상ㆍ전라ㆍ제주도가, 치료결과가 호전된 경우, 기타진단이 있는 경우, 협진을 시행한 경우, 전과를 한 경우, 중환자실을 이용한 경우, 일반검사를 시행한 경우, 특수검사ㆍ처치를 시행한 경우에서 재원일수 CMI가 길어지는 방향으로 영향을 미쳤으며, 의뢰군은 기준군인 일반군에 비해, 퇴원과는 내과에 비해 외과계에서, 수술을 시행한 경우에서 재원일수 CMI가 짧아지는 방향으로 영향을 미쳤다.

6. 2차 분석으로 의뢰군의 다빈도 10대 주진단 환자를 일반군 환자와 1:1 짝짓기하여 치료결과에 영향을 미치는 요인을 조사하기 위하여 다중 로지스틱 회귀분석을 한 결과, 연령이 증가할수록 치료결과가 비호전되는 방향으로 영향을 미쳤으며, 퇴원과의 경우는 외과계에서, 일반검사는 검사를 시행한 경우 치료결과가 호전되는 방향으로 영향을 미쳤다.

위의 분석결과, 진료의뢰센터는 1차ㆍ2차 지역사회병원과 더불어 발전하는 역할을 담당하고 3차 의료기관으로서 자발적인 민간주도의 의료전달체계를 확립하는데 이바지하였다고 할 수 있으며, 향후 진료의뢰센터가 병원경영의 전략적 차원에서의 역할을 수행하도록 진료정보를 이용한 보다 심도있고 다양한 연구가 계속 진행되어야 할 것이다.

[영문]This study compared the characteristics of medical care services utilization between the group of inpatients via referral centers (the referral group) and the group of inpatients via different routes (the general group), and analyzed the case-mix index of length of stay(CMI of LOS) to adjusted with the disease. As a second step, this study analyzed the results of treatment through making pairs of patients with the 10th primary diagnoses of multiple frequencies of the referral group to the patients of the general group and investigated the operation of referral centers. The 9,484 cases of newly inpatients of 2003 were used for the data and it was analyzed by SAS (Statistical Analysis System) version 8.01.

The results of the study were as follows;

1. On the subjects of total patients, I compared the characteristics of medical care services utilization between the referral group and the general group. From the Socio-demographic characteristics, the jobs of referral group were shown to be higher in office and service works, farming and forestry related vocations, and housekeeping. The areas of residence of the referral group were mostly Seoul, neighboring Geonggi-do, Gyeongsang-do, Jeolla-do, and Jeju-do.

2. From the characteristics of medical care service information, CMI of LOS was 0.94 in the referral group, which was shorter than 1.01 in the general group. The average length of stay was 7.5days in the referral group, which was 0.6day shorter than that in the general group. The discharging department of the referral group showed to be higher in the internal medicine and surgery. In addition, the referral group showed significantly higher rate when other diagnoses were made, corporate treatment was implemented, transferred, and operations or general medical test were done.

3. From the characteristics of diagnostic information, I compared the distribution of principle diagnoses upon the 21 chapter of the 4th amendment of Korean Standard Classification of Diseases, the results were that neoplasm was shown to be the highest distribution in both groups, the most frequent diseases in the referral group were neoplasm and circulatory disease.

4. This study divided the request group according to request hospital into three sub-groups - cooperative treatment hospitals

clinics, cooperative hospitals and other hospitals - and compared their characteristics related to medical care information. According to the results, the length of stay was longer, cooperative treatments were more frequent, and the numbers of general tests, special tests and treatments were higher in cases requested to cooperative hospitals than in those requested to cooperative treatment hospitals/clinics.

5. In the results of multiple regression analysis upon the CMI of LOS, the CMI of LOS was highly affected by other vocations over the specialized professions of the standardized vocation, the areas of Gyeongsang-do, Jeolla-do, and Jeju-do over Seoul or neighboring Geonggi-do of the standardized area. Additionally, the CMI of LOS was shown longer in the improvement of disease, when other diagnosis was made, cooperated treatment was implemented, transferred, intensive care unit was used, general examination was done, and special examination and treatment were done. However, the CMI of LOS was shown shorter in the referred group compared to the general group, surgical department compared to internal medicine as a discharge department, and the patients performed operation.

6. As a secondary analysis for the result of treatment, in the Multiple Logistic Regression Analysis through the pairing of the patients with 10th primary diagnosis of multiple frequencies of the referred group to the patients of the general group, the result of treatment was shown less improved with age, discharge rate was shown higher in the surgical department, and the result of treatment was better when general examination was done.

With the result, referral centers can be said to play an important role in improvement of medical care services along with primary and secondary community hospitals and, contribute to establishing voluntary private organization initiated medical care delivery system as a tertiary medical center. Furthermore I suggest that variety of depth studies on referral centers at the strategic level of hospital management by medical information should be continued in the future.