노인의 대퇴전자간 골절의 수술적 방법에 따른 임상적 특성 및 의료비용 비교

Abstract

[한글]

노인의 대퇴전자간 골절의 수술적 방법에 따른 임상적 특성 및 의료비용을 비교분석함으로써 증가하는 의료비용의 지출감소와 요양급여 적정성 평가와 심사에 도움이 되는 기초자료를 제공하고자 하였다. 이 연구는 대퇴전자간 골절의 수술적 방법에 따른 임상적 특성 및 의료비용을 비교하기위한 2차 분석을 통한 서술적 상관관계연구이다.연구대상은 전국 42개 3차전문요양기관의 2004년 진료내역 중 건강보험심사평가원에 전산청구된 65세 이상 노인의 건강보험 입원건의 청구명세서에 근거하여, 수술을 시행한 총2202건-감마정316건, 양극성 고관절 반치환술1138건, 압박고나사748건을 대상으로 분석하였다. 연구도구는 문헌고찰을 근거로 기존보험청구자료의 2차분석을 통한 조사표를 이용하여 대퇴전자간 골절의 일반적 특성, 임상적 특성, 의료비용을 진료건수, 수진자수, 총진료비, 평균진료비로 파악하였다. 자료분석방법은 SAS Package Version 8.02를 이용하여 전산처리하였고 연구결과는 다음과 같다.1. 일반적 특성은 수술적 방법에 따라 성별(=8.48, P=0.0144), 의료기관소재지별(=39.73, P<.0001)에서 유의한 차이를 보였고, 다빈도 부상병은 유의한 차이를 보이지 않았다.2. 임상적 특성에서 수술적 방법에 따른 재원일수, 중환자실재원일수, 투약일수는 유의한 차이를 나타내지 않았고, 마취시간(F=43.23, P<.0001)과 수혈량(F=3.09, P=0.0458)은 유의한 차이를 보였다.3. 의료비용에서 수술적 방법에 따른 건당평균진료비는 양극성 고관절 반치환술이 6,158,325± 1,630,815원으로 가장 많았고, 감마정이 4,368,149± 1,371,752원, 압박고나사가 4,160,496± 1,639,120원으로 유의한 차이를 보였다(F=404.89, P<.0001). 항목별진료비도 처치 및 수술(F=3261.28, P<.0001), 투약/주사/수혈(F=5.32, P=0.0050), 검사/영상진단/CT/MRI(F=5.20, P=0.0056), 마취(F=26.07, P<.0001), 이학요법/정신요법(F=6.23, P=0.0020)에서 유의한 차이를 나타내었다.결론적으로, 의료비용의 차이는 항목별진료비중 처치 및 수술항에 의한 것으로 이는 치료재료대 가격의 차이에 의한 것으로 사료된다. 고가의 치료재료비용이 소요되는 대퇴전자간 골절수술은 노인인구증가와 국민소득의 증가로 삶의 질 향상욕구가 증대됨에 따라 지속적으로 증가할 것이다. 이에 수술방법과 사용재료대에 따라 의료비용에 차이가 있고 국민을 의학적으로 보호하고 의료의 질 향상과 의료비 절감을 위하여 고가의 치료재료비용이 소요되는 대퇴전자간 골절수술은 수술대상과 방법선정에 신중을 기할 필요가 있다.이 연구는 향후 본 질환과 연관된 의료심사의 재원일수와 의료비용의 적정성 평가뿐만 아니라, 수술적 방법의 선택의 타당성 평가, 적정성 유도를 위한 임상진료지침의 기초자료로 활용가능하리라 판단된다.

[영문]

In this study, both clinical characteristics and medical cost were comparatively between the surgical operation modalities for intertrochanteric fracture. For the correlation study, the method of second order analyses was employed. This work aimed to provide the fundamental data to assess the propriety of review of medical treatment expense and ultimately assist to reduce a medical cost.The basic data for analyses were acquired from the database of the Health Insurance Review Agency. The cases were collected among the treatment in tertiary hospitals in 2004, considering the collecting boundary of the patients older than 65. Out of the total treatments, 2202 cases were selected for statistical analyses, in which a surgical operation was carried out; 316 cases of gamma nail, 1138 cases of bipolar hemiarthroplasty, and 748 cases of hip compressing screw. The second order analyses were based on the data from literature survey. As the statistical variable to evaluate the general characteristics, the clinical characteristics and the medical cost against the operation modality, the number of treatment case, the treatment rate, the total medical expense, and the average expense per case were considered. Data analyses were carried out using the computational code package of SAS Package Version 8.02. The obtained results are summarized as follows:1. In the analyses of the general characteristics, the distributions of operation modality showed the significant difference according to both gender (=8.48, P=0.0144) and location of institution (=39.73, P<.0001). However, as far as a frequent occurring disease is concerned, any significant difference in the operation modality could not be found.2. In the clinical characteristics analyses in terms of duration of hospitalization, duration in intensive care unit, and duration of medication, there was no significant difference between operation modality. However, any significant difference was not found in anesthesia time(F=43.23, P<.0001) and blood transfusion(F=3.09, P=0.0458).3. When we consider medical expense against operation modality, the average cost per treatment was high in the bipolar hemiarthroplasty, 6,158,325± 1,630,815 won. The modalities of both gamma nail, and hip compressing screw also showed the significant difference in the average cost(F=404.89, P<.0001), which was 4,368,149± 1,371,752 and 4,160,496± 1,639,120 won, respectively. The significant difference was shown according to the medical expense for each item such as treatment/operation(F=3261.28, P<.0001), medication/injection/blood transfusion(F=5.32, P=0.0050), test/image diagnosis/CT/MRI(F=5.20, P=0.0056), anesthesia (F=26.07, P<.0001), physiotherapy/psychotherapy(F=6.23, P=0.0020).In conclusions, the difference in medical expense is originated mainly by the difference in the cost for treatment/operation out of the considered items. We can consider that the difference results from the cost of treatment materials. The intertrochanteric fracture, which requires high cost of treatment materials, shall increase continuously since the population of aged man will be increased and the desire for improved quality of life will be also increased by the increased national income. Furthermore, it should be reminded that the difference in medical expense is significant according to used materials as well as operation modality. In this point, as far as intertrochanteric fracture is concerned, the more careful consideration should be taken to determine both object and modality of operation, in order to improve the quality of medical care and reduce the medical cost to protect the people medically.It is expected that the obtained results can be utilized as the basic informations to assess not only the propriety of medical review but also the reasonableness of selection of operation modality, to set up a guideline on clinical examination and treatment.