고혈압∙당뇨병 복합질환자를 고려한 적정성 평가 개선 방안

Abstract

The Health Insurance Review and Assessment Service(HIRA) has implemented a quality assessment program since 2010 to improve the quality of medical care and reduce the risk of cardio-cerebrovascular disease by improving the management quality of patients with hypertension and diabetes. With the increased prevalence of chronic diseases and aging populations, the modern generation generally suffers from multiple (two or more) chronic conditions simultaneously, regardless of the types of diseases. Among the patients targeted for quality assessment, 23.4% with hypertension and 59.4% with diabetes were identified as patients with multi-morbid conditions in 2019. Thus, this study proposed measures for enhancing quality assessment program and redesigning relevant compensation systems considering muti-morbid patients with hypertension and diabetes. Therefore, this study analyzed the current state of quality assessments program of hypertension and diabetes. It also examined international quality assessments systems, such as indicators for assessments and result analysis methods, to derive implications for assessments model design. Moreover, it designed a quality assessment model that considers patients with hypertension and diabetes, based on implications derived from the analytical results of present conditions and international cases. Specifically, it listed preliminary indicators by reviewing existing literature, such as international quality assessment indicators, and Korean and international clinical practice guidelines. Further, it classified the listed indicators as generic and disease-specific indicators. Subsequently, it established a panel of experts and selected quality assessment indicators based on the panel’s opinions. It also examined a method that uses the selected quality assessment indicators to calculate a score based on the clinic unit and presented a grading method according to the calculated score. Finally, this study developed a method for providing incentives based on the unit of a clinic to replace the existing method of incentivizing based on the disease. The developed method reflects the existing method that incentivizes based on the number of patients managed and sections, to consider acceptance of systems among medical institutions. However, the developed method is distinguished from the existing method in that it differentiates the level of compensation according to grades and disease types(e.g., a single disease and multiple diseases). Additionally, this study presented a mid- and long-term direction for quality assessment indicators and compensation systems. quality assessment indicators are constantly required for implementing outcome indicators. Consequently, further research should be conducted to develop a method that reduces clinical burdens on data submission other than the claim data and to adjust the assessment results based on each medical institution by reflecting the patients’ characteristics. The results of this study may be used as the base data for further research on quality assessment improvement.