항생제 사례로 살펴본 건강보험청구자료 분석 시 고려사항

Abstract

The Health Insurance Review & Assessment Service (HIRA) collects and stores medical information of all citizens and medical institutions, including pharmaceutical claims data. Claims data including consultation notes and information about the medical institution are submitted to the HIRA by medical providers. Claims data have potential to offer a high quality for research, but various factors must be strongly considered in its analysis and interpretation. This study highlights various points to be considered while utilizing claims data. First, the time period between a claims review and loading of the data onto a data warehouse (DW) must be taken into account because over 99% of claims are available on DW for extraction after 5 months, according to an analysis of claims rate for pharmaceutical expenses. Second, over 50% of pharmaceutical claims data consists of reimbursable items, of which over 99% are antimicrobial medications. Accurate determination of the precise usage of nonreimbursable pharmaceuticals is limited to estimations based on the data on pharmaceutical supply declaration, which is only partially reported on claims statements as part of the comprehensive fees system. Finally, complete data on the use of pharmaceuticals during inpatient admission is unavailable. Due to the lack of requirement to input the administration time or to differentiate prescriptions on the day of discharge, it is difficult to accurately calculate the used amounts. These factors must be considered prior to analysis and interpretation of claims data from the HIRA. Hence, to ensure a higher research quality, we recommend considering these factors when conducting a claims data-based research.