적정성 평가 제외 요양기관의 질 수준과 관리 방안

  • 16
  • 44
Metadata Downloads
Research report
Issued Date
요양급여 적정성 평가사후관리Quality AssessmentQuality Level and ManagementHealth Insurance Review & AssessmentHIRA
As of 2023, the National Health Insurance Review and Assessment Service in South Korea conducts healthcare appropriateness assessments for a total of 37 items. During the course of conducting these assessments and deriving indicators, there arise instances where some healthcare providers are excluded. Understanding the reason of these excluded healthcare providers becomes necessary. Therefore, this study aims to comparatively assess healthcare providers undergoing healthcare appropriateness assessments and those excluded from the assessment process. Additionally, this study seeks to explore post-assessment management strategies for the healthcare providers excluded from the assessment process.
To determine the scope of this study, we have reviewed a total of 37 assessment items. We excluded assessment items from this study for which healthcare providers need to submit surveys before indicators are generated. The reason for this exclusion is that indicator reproducibility is not possible without the process of resending surveys to healthcare providers. Due to limitations in time and resources for the study, indicators were created only using claim data. We selected hypertension, diabetes, chronic obstructive pulmonary disease(COPD), and asthma assessment items that we can replicate as the focus of this study.
We divided healthcare providers into two or four groups based on the most recent assessment results of the four assessment items. In the final indicator aggregation process, we used well-performing healthcare providers as the reference group. And We used the excluded institutions from each assessment process as the comparison group. Subsequently, we compared the differences in indicators between the groups using statistical methods. Due to the lack of normality, we conducted the non- parametric Kruskal-Wallis rank sum test.
The analysis results indicated that, in general, statistically significant disparities existed between the groups. The reference group displayed elevated quality indicator values compared to the comparison group. However, within certain specific indicators and healthcare providers, even among the comparison group, there were instances where indicator values surpassed those of the reference group. Broadly speaking, general hospitals and higher-tier healthcare providers consistently exhibited indicator values at or exceeding the level of the reference group. In contrast, for healthcare providers at the small size hospital level, it was discerned that targeted post-assessment management interventions were necessary.
For the enhancement of healthcare quality on a national level, it is important to share the objectives and directions of the assessment program with all participating healthcare providers. This entails not only improving the overall average, but also reducing intra-group variation to mitigate disparities. Establishing a direction to diminish qualitative differences is deemed essential.
Regarding future management approaches such as monitoring and feedback, I recommend referring to this report for guidance. The insights within this report can serve as a valuable reference for formulating strategies that encompass continuous monitoring and feedback, facilitating the enhancement of healthcare quality standards across the nation.
Alternative Title
Quality Levels and Management Plans of Medical Institutions Excluded from Quality Assessment
Table Of Contents
제1장 서론 ··········································································· 3
1. 연구 배경 ······························································································ 3
2. 연구 목적 ······························································································ 4
3. 연구 내용 ······························································································ 4
4. 연구 방법 ······························································································ 4

제2장 요양급여 적정성 평가 항목별 대상기관 제외기준 ··········································································· 9
1. 요양급여 적정성 평가 항목별 제외기준 검토 ············································· 9
가. 요양급여 적정성 평가 현황 ·········································································· 9
나. 요양급여 적정성 평가 제외기준 분류 ·························································· 10
2. 요양급여 적정성 평가 항목별 제외기준 ··················································· 12
가. 고혈압 ····································································································· 12
나. 당뇨병 ····································································································· 15
다. 천식 ········································································································ 18
라. 만성폐쇄성폐질환(COPD) ·········································································· 20

제3장 제외기관과 평가기관의 질 지표 비교 ··········································································· 25
1. 연구 대상 정의 ···················································································· 25
가. 고혈압 ····································································································· 25
나. 당뇨병 ····································································································· 29
다. 천식 ········································································································ 33
라. 만성폐쇄성폐질환(COPD) ·········································································· 36
2. 평가 항목별 질 지표 비교 ····································································· 39
가. 고혈압 ····································································································· 39
나. 당뇨병 ····································································································· 58
다. 천식 ········································································································ 84
라. 만성폐쇄성폐질환(COPD) ········································································· 106
3. 소결 ·································································································· 111

제4장 요양급여 적정성 평가 이후의 관리 방안 ··········································································· 115
1. 현재 요양급여 적정성 평가 결과에 따른 질 관리 활동 ··························· 115
가. 요양기관 통보 ························································································ 115
나. 평가 결과 공개 ······················································································· 115
다. 질 향상 지원사업 ···················································································· 116
2. 적정성 평가 이후 질 관리 개선 제안 ···················································· 117
가. 질 관리 대상기관의 확대 및 세분화 ·························································· 118
나. 질 향상 관리 방식의 개선 ······································································· 119

◾ 참고 문헌 ····················································································· 123
◾ 부록 ····························································································· 125
◾ ABSTRACT ················································································· 159
이성우. (2023-08). 적정성 평가 제외 요양기관의 질 수준과 관리 방안.
Appears in Collections:
HIRA 연구 > 1. 자체연구
Authorize & License
  • Authorize공개
Files in This Item:

열람하신 정보에 대해 만족하십니까?


Items in Repository are protected by copyright, with all rights reserved, unless otherwise indicated.