지역사회 의료자원 이용의 효율성과 건강수준 간의 관련성 분석 -서울,경기 지역을 중심으로-

곽진미 ( Jin-mi Kwak ),이광수(교신저자) ( Kwang-soo Lee ),서은원 ( Eun-won Seo ) 대한보건협회 2016 대한보건연구 Vol.42 No.2

연구목적: 본 연구는 지역의 의료자원 대비 의료서비스 이용에 초점을 두어 서울과 경기지역을 중심으로 지역사회 의료자원 이용의 효율성과 지역 내 주민의 건강수준 간의 관련성을 분석하였다. 연구방법: 2013년 기준으로 국민건강보험공단, 통계청, 보건복지부에서 제공하는 데이터를 활용하였으며, 분석단위는 서울과 경기 지역의 56개 시·군·구이다. 의료자원 이용의 효율성 점수를 계산하기 위해 자료포락분석을 사용하였고, 의료자원이용의 효율성과 지역 내 주민의 건강수준 간의 관련성 파악을 위해 구조방정식을 활용하였다. 연구결과: 분석결과 의료자원 이용의 효율성과 건강 수준 간에 통계적으로 유의미한 관련성은 없는 것으로 나타났다. 고등학교 이상 졸업자 분율, 주민등록인구수, 시·군·구 유형은 건강수준과 유의미한 관련성을 보였다. 결론: 본 연구는 지역의 건강 관리는 의료서비스 이용에 치중하기보다는 복합적이며 다학제적인 방식으로 접근할 필요가 있음을 시사한다. 또한 지역사회 수준에서의 건강관리를 하기 위해서는 탈시설화 개념을 도입하고, ACO와 같이 지역 내에서 건강을 통합 관리하는 지역사회 의료중심 체제를 갖추는 것이 필요할 것으로 판단된다. Objective: This study analyzes the relationship between the efficiency of regional health care resource uses and health status of population focusing on Seoul and Gyeonggi Province in South Korea. Methods: Data was collected from the 2013 statistical yearbook published by the National Health Insurance Corporation, Statistics Korea, and the Ministry of Health and Welfare. Study units included 56 basic local governments, city (si in Korean), county (gun in Korean) and district (gu in Korean), in 2013. Data envelopment analysis (DEA) with input-oriented BCC model was applied to produce efficiency score. Structural equation modeling (SEM) was applied to explore the relationship between efficiency of regional health care resource uses and health status of population. Variables such as the percentage of high school graduates, population size, types of local government, level of subjective health awareness, and level of financial independence were included in the model to control their differences among regions. Results: Analysis result showed that the efficiency of regional health care resource uses were not statistically related to health status. Regional variables such as the percentage of high school graduates, population size, and county local government were found to have significant relationships with health status. Conclusion: It suggests that it is need to manage the health of local residents with multidisciplinary approaches consisted with various members of the local health system organizations rather than mainly focusing on health service uses. Health policy makers will require introducing the concept of deinstitutionalization and building an integrated community health to manage the health of population.

입원서비스의 집중화 수준과 진료비 간의 관계 분석: 2009년~2011년

곽진미 ( Jin Mi Kwak ),이광수 ( Kwang Soo Lee ),권혁준 ( Hyuk Jun Kwon ) 한국지식경영학회 2015 지식경영연구 Vol.16 No.1

Previous studies provided that limiting the number of services provided in hospital had influences in decreasing cost in delivering medical services. Hospitals could have positive effects on their profit by concentrating small number of services which they have comparative advantages. This study purposed to analyze the relationship between the concentration status of hospitals and medical charge for inpatients. National Inpatient sample data provided by the Health Insurance Review and Assessment Service (HIRA) for three years, 2009 to 2011 was used to compute the three concentration indices (Information Theory Index (ITI), Internal Herfindahl Index (IHI), and number of distinct Diagnosis-Related Groups (DRGs) treated) and total medical charge per inpatient case in each year. It was also used to select the control variables such as bed size, number of doctors per 100 beds, and locations. The ordinary least square regression models were developed and tested for hospital and general hospitals separately. The results showed that the total medical charge per inpatient case was significantly differed depending on the concentration indices, and there were positive relationships in ITI and IHI. The number of distinct DRGs had different directions in regression coefficients depending on the locations and hospital types. Hospitals had larger absolute standardized regression coefficients compare to those of general hospitals. However, their effects could be varied by the hospital types, number of doctors, and locations. It seems that hospitals have more influences on medical charges by concentrating their services than general hospitals. Study results provide knowledges to hospital administrators that concentration strategy can positive influences on the performance of small size hospitals.

병원서비스지역 내 병원자원과 의료서비스 이용 간의 관련성 분석

곽진미 ( Jin Mi Kwak ),김다양 ( Da Yang Kim ),서은원 ( Eun Won Seo ),이광수 ( Kwang Soo Lee ) 한국보건행정학회 2015 보건행정학회지 Vol.25 No.3

Background: This study explored the relationship between hospital resources and services uses in outpatient/inpatient-based hospital service area (HSA) in Korea. Methods: Study hospitals included all acute care hospitals except tertiary hospitals. Inpatient and outpatient hospital claims from the Korean National Health Insurance (NHI) program in 2010 were used to identify the service uses. Hospital resources and the degree of insurance premium in study areas were identified with the NHI corporation data. Study variables were computed by summing the service uses or hospital resources of study hospitals in each HSA. Service uses were represented by the total medical charges and number of visits/inpatient days. Hospital resources were measured by number of beds, number of doctors, and number of computed tomography (CT). The economic status of NHI enrollees in each HSA was controlled by the average monthly premium of NHI program per household in each HSA. The degree of using local hospitals was controlled with the localization index. Results: Analysis results showed that hospital resources such as beds, CT were statistically related to the service uses. And also localization index was found to have positive significant relationships with service uses. Conclusion: Hospital resources such as beds, CT had not only positive impacts on inpatient service uses, but also influences on the outpatient setting. Health policy makers will require monitoring and assessing the hospital resources in Korea.

Diagnosis-Related Group 지불제도가 위험도 보정 제왕절개 분만율에 미치는 영향

곽진미 ( Jin-mi Kwak ),이광수 ( Kwang-soo Lee ) 한국보건행정학회 2021 보건행정학회지 Vol.31 No.2

Background: This study analyzed the effect of applying the diagnosis-related group (DRG)-based payment system, which was implemented in July 2012 for hospitals and clinics nationwide, on the cesarean section rate. Methods: The subjects of the study were divided into new groups that participated in the payment system after July 2012 and maintenance groups that participated in the payment system before July 2012. As an analysis method, a difference-in-difference analysis, which is a quasi-experimental design, was used. The risk-adjusted cesarean section rate was used as a dependent variable. Results: Seven risk factors (malpresentation of fetus, eclampsia, multiple pregnancies, problems in the placenta, previous Cesarean section, cephalopelvic disproportion, problems in amniotic fluid) were included in the final risk-adjustment model, and found to have a statistically significant relationship with the cesarean section rate. Results showed that the risk-adjusted cesarean section rate increased significantly in new groups after the application of the DRG-based payment system. Conclusion: Study results provided policy implications for the reorganization of the DRG-based system should that reflects the demands of obstetricians, such as organizing a consultative body with obstetricians and establishing a reasonable fee.

성별에 따른 지역 간 자살률 차이 및 영향요인 분석

서은원 ( Eun Won Seo ),곽진미 ( Jin Mi Kwak ),김다양 ( Da Yang Kim ),이광수 ( Kwang Soo Lee ) 한국보건행정학회 2015 보건행정학회지 Vol.25 No.4

Background: Suicide is one of important health problems in Korea. Previous studies showed factors associated with suicide in individual levels. However, suicide was influenced by society that individuals belong to, so it was required to analyze suicide in local levels. The purpose of this study was to analyze the regional disparities of suicide mortality by gender and the association between local characteristics and suicide mortality. Methods: This study included 229 city·county·district administrative districts in Korea. Age- and sex-standardized suicide mortality and age-standardized suicide mortality (male/female) were used as dependent variables. City·county·district types, socio-demographics (number of divorces per 1,000 population, number of marriages per 1,000 population, and single households), financial variable (financial independence), welfare variable (welfare budget), and health behavior/status (perceived health status scores and EuroQol-5 dimension [EQ-5D]) were used to represent the local characteristics. We used hot-spot analysis to identify the spatial patterns of suicide mortality and negative binomial regression analysis to examine factors affecting suicide mortality. Results: There were differences in distribution of suicide mortality and hot-spot regions of suicide mortality by gender. Negative binomial regression analysis provided that city·county·district types (city), number of divorces per 1,000 population, financial independence, and EQ-5D had significant influences on the age- and sex-standardized suicide mortality per 100,000. Factor influencing suicide mortality was the number of divorces per 1,000 population in both male and female. Conclusion: Study results provided evidences that suicide mortality among regions was differed by gender. Health policy makers will need to consider gender and local characteristics when making policies for suicides.

의료보장유형이 심부전 입원 환자의 의료서비스 이용에 미친 영향분석: Propensity Score Matching 방법을 사용하여

최소영 ( Soyoung Choi ),곽진미 ( Jin-mi Kwak ),강희정 ( Hee-chung Kang ),이광수 ( Kwang-soo Lee ) 한국보건행정학회 2016 보건행정학회지 Vol.26 No.4

Background: This study aims to analyze the effects of insurance types on the medical service uses for heart failure inpatients using propensity score matching (PSM). Methods: 2014 National inpatient sample based on health insurance claims data was used in the analysis. PSM was applied to control factors influencing the service uses except insurance types. Negative binomial regression was used after PSM to analyze factors that had influences on the service uses among inpatients. Subjects were divided by health insurance type, national health insurance (NHI) and medical aid (MA). Total charges and length of stay were used to represent the medical service uses. Covariance variables in PSM consist of sociodemographic characteristics (gender, age, Elixhauser comorbidity index) and hospital characteristics (hospital types, number of beds, location, number of doctors per 50 beds). These variables were also used as independent variables in negative binomial regression. Results: After the PSM, length of stay showed statistically significant difference on medical uses between insurance types. Negative binomial regression provided that insurance types, Elixhauser comorbidity index, and number of doctors per 50 beds were significant on the length of stay. Conclusion: This study provided that the service uses, especially length of stay, were differed by insurance types. Health policy makers will be required to prepare interventions to narrow the gap of the service uses between NHI and MA.

공간분석을 이용한 지역별 비만율에 영향을 미치는 요인분석

김다양 ( Da Yang Kim ),곽진미 ( Jin-mi Kwak ),서은원 ( Eun-won Seo ),이광수 ( Kwang-soo Lee ) 한국보건행정학회 2016 보건행정학회지 Vol.26 No.4

Background: This study purposed to analyze the relationship between regional obesity rates and regional variables. Methods: Data was collected from the Korean Statistical Information Service (KOSIS) and Community Health Survey in 2012. The units of analysis were administrative districts such as city, county, and district. The dependent variable was the age-sex adjusted regional obesity rates. The independent variables were selected to represent four aspects of regions: health behaviour factor, psychological factor, socio-economic factor, and physical environment factor. Along with the traditional ordinary least square (OLS) regression analysis model, this study applied geographically weighted regression (GWR) analysis to calculate the regression coefficients for each region. Results: The OLS results showed that there were significant differences in regional obesity rates in high-risk drinking, walking, depression, and financial independence. The GWR results showed that the size of regression coefficients in independent variables was differed by regions. Conclusion: Our results can help in providing useful information for health policy makers. Regional characteristics should be considered when allocating health resources and developing health-related programs.

정신질환 관련 의료자원 이용의 생산성 변화 분석

서은원 ( Eun Won Seo ),곽진미 ( Jin Mi Kwak ),진다빈 ( Da Bin Jin ),이광수(교신저자) ( Kwang Soo Lee ) 한국보건경제정책학회(구 한국보건경제학회) 2016 보건경제와 정책연구 Vol.22 No.1

본 연구는 맘퀴스트 생산성 지수(Malmquist Productivity Index, MPI)를 이용하여 정신질환 관련 의료자원 이용의 7년 간 생산성 변화 추이를 지역별로 분석하였다. 분석 단위인 DMU(DecisionMaking Units)는 16개 광역시·도이며 중앙정신보건사업지원단에서 제공하는 7개년 자료(2007-2013년)를 이용하였다. 맘퀴스트 생산성 지수 분석에 사용된 투입변수는 정신 의료기관 수,정신 병상 수, 정신과 전문의 수이며 산출변수는 정신 의료기관에 입원 및 외래로 방문한 환자수이다. 분석 결과, 생산성은 전반적으로 평균 0.6% 증가하였고 이 생산성 증가에 주된 영향을 미치는 요인은 기술 변화로 나타났다. 또한 지역별로 생산성 변화에 큰 차이가 있었는데, 평균적으로 생산성 증가가 크게 나타난 지역은 강원, 서울이었던 반면 생산성 감소가 큰 지역은 인천,제주였다. 본 연구는 7년 간 우리나라 정신질환 관련 의료자원 이용의 생산성 추이를 지역별로 파악할 수 있었고, 앞으로의 정신질환 관련 의료자원 이용 계획 수립 시 기초자료로 활용될 수있을 것이다. This study purposed to analyze the productivity trend of healthcare resources utilization about mental health by region in Korea. Data were derived from the National Mental Health Commission and this study included 16 metropolitan cities for 7 years from 2007 to 2013. To analyze productivity change using Malmquist Productivity Index(MPI), number of mental hospitals, number of mental hospital beds and number of psychiatrists were used as input variables. Number of inpatients and outpatients were used as output variables. Overall, MPI was increased by 0.6% on average during the period from 2007 to 2013. Technical change had more influence on productivity advance than pure efficiency change and scale efficiency change. There were differences in MPI by regions. Gangwon showed the highest productivity increase, while Incheon showed the highest productivity decrease. Study results presented that productivity change of healthcare resources utilization about mental health was differed by regions and that technical changes were mainly due to productivity change. Thus, health policy makers will need to prepare interventions to use resources about mental health efficiently by regions.

수면장애가 외래 진료서비스 이용에 미친 영향분석

동재용 ( Jae-yong Dong ),이광수 ( Kwang-soo Lee ),곽진미 ( Jin-mi Kwak ),김기영 ( Ki-young Kim ) 대한보건협회 2016 대한보건연구 Vol.42 No.4

연구목적 : 수면장애 질환이 외래 진료서비스 이용에 미친 영향을 분석하는데 목적이 있다. 연구방법 : 한국보건사회연구원과 국민건강보험공단이 공동으로 수집하는 한국의료패널 2012년 자료를 사용하였다. 분석대상은 9,721명이며, 분석방법은 성향점수매칭방법(Propensity Score Matching, PSM), 감마 회귀분석과 음이항 회귀분석을 실시하였다. 연구결과 : 수면장애 질환은 총 외래 진료비와 외래 방문 횟수에 유의한 영향이 있었고, 회귀계수 값은 0.97(95% CL : 0.78 ~ 1.16)과 1.06(95% CL : 0.91 ~ 1.21)으로 나타났다. 성별과 교육수준은 총 외래 진료비만 유의한 영향이 있으며 성별의 회귀계수 값은 -0.21(95% CL : -0.40 ~ -0.30), 교육수준(초등학교, 고등학교)의 회귀계수 값은 -0.34(95% CL : -0.60 ~ -0.14) 및 -0.37(95% CL : -0.61 ~ -0.03)로 나타났다. 총 외래 방문 횟수는 수면장애 질환 변수 외 유의한 영향이 있는 변수가 없었다. 수면장애 질환 환자는 총 외래 진료비를 평균 약 126만원을 사용하였으나, 비 수면장애 질환 환자는 평균 약 50만원을 사용하였다. 또한 수면장애 질환 환자는 총 외래 방문 횟수가 평균 약 52회로 나타났으나, 비 수면장애 질환환자는 평균 약 20회로 나타났다. 결론 : 수면장애 질환은 사용하는 외래 진료비가 높으며 외래 의료기관을 방문하는 횟수도 많다. 환자들이 부담하는 진료비 외에도 사회·경제적으로 많은 비용과 문제들이 발생하고 있어 수면장애 질환에 대한 관심이 필요하다. Objective: This study purposed to analyze the effects of sleep disorders on the outpatient service uses. Methods : Data was provided from the Korea Health Panel(KHP) collected by the Korea Institute for Health and Social Affairs(KIHASA) and National Health Insurance Service(NHIS) in 2012. The number of sample is 9,721 people. This study was used Propensity Score Matching(PSM) and Gamma regression and Negative Binominal regression. Results : First, sleep disorders had significant effects on the total outpatient charges and total outpatient visits. The coefficient was 0.97(95% CL : 0.78 ~ 1.16) and 1.06(95% CL : 0.91 ~ 1.21) in sleep disorders. Second, gender and education level had significant effects on the total outpatient charges. The coefficient was - 0.21(95% CL : -0.40 ~ -0.30) in gender. The coefficient was -0.34(95% CL : -0.60 ~ -0.14) and -0.37(95% CL : -0.61 ~ -0.03) in education level. Third, other variables had not significant effects on total outpatient visits besides sleep disorders. Conclusion : Sleep disorders have an impact on outpatient medical charges and visits. In addition to, patient with sleep disorders have a lot of socio-economic burden besides medical charges. Health policy markers should be interested in sleep disorders.

지역사회 획득 폐렴 발생의 지역적 변이 및 지역요인과의 관계 분석

박성용 ( Seong Yong Park ),이광수 ( Kwang Soo Lee ),곽진미 ( Jin Mi Kwak ) 대한보건협회 2016 대한보건연구 Vol.42 No.1

연구목적 : 본 연구는 지역을 분석단위로 하여 지역의 사회·경제·복지적 특성과 지역사회 획득 폐렴 발병 간의 관계를 분석하고자 한다. 연구방법 : 연구는 219개 시·군·구를 분석단위로 한 단면적 연구이다. 2010년 발간된 제 6차 퇴원손상심층조사 원시자료를 이용하여 2009년 발생한 각 시·군·구 지역사회 획득 폐렴 환자 수를 추정하였으며, 지역 간 인구구조의 차이를 성별과 연령을 이용하여 보정하였다. 지역특성은 인구사회학적(고령인구비율, 65세 이상 인구, 인구 10만 명당 결핵 환자 수), 경제적(인구10만 명당 기초생활 수급자 수, 지역별 1인당 연간 보험료), 그리고 복지적(독감예방접종률, 인구 10만 명당 사회복지시설)특성을 반영할 수 있는 변수를 선정하였다. 분석은 다변량 회귀분석(multivariate regression analysis)와 공간분석방법인 지리적 가중회귀분석(geographically weighted regression)을 이용하였으며, 통계분석을 위해 SAS ver. 9.3과 ArcGIS ver. 10.0을 이용하였다. 연구결과 : OLS 회귀 분석 결과에서, 인구 10만 명당 기초생활 수급자 수와 고령인구비율이 인구 10만명 당 지역사회획득 폐렴 환자수와 유의미한 양의 관계를 보였다. GWR을 적용한 결과 OLS 분석에서 산출된 회귀계수와 GWR로 산출된 국지적 회귀계수들 사이에 차이가 있었으며, 그리고 지역에 따라 회귀계수에 차이가 있었다. 결론 : 폐렴 발생과 관련된 지역수준의 요인의 영향 정도에는 지역에 따라 차이가 있는 것으로 파악되었다. 연구에서 사용한 지역변수 이외의 변수를 추가하여 폐렴에 영향을 미치는 요인에 대해 연구가 이루어진다면, 좀 더 지역 상황에 맞는 세부적인 정책을 마련하는데 도움이 될 수 있을 것이다. Objective: Community-Acquired Pneumonia (CAP) is the most frequently occurred infectious disease in Korea, and previous studies analyzed the occurrences of CAP were mainly focused on the personal level. This study purposed to analyze the regional variation of CAP occurrences and the relationships between the CAP occurrences and regional factors using spatial analysis method. Methods: Cross sectional study design was applied with data collected from the 219 city gun(county in Korean)·gu(district in Korean) administrative regions in South Korea. Korean National Hospital Discharge In-depth Survey (NHDIS) in 2009 provided by Korea Centers for Disease Control and Prevention (KCDC) was used to identify the CAP occurrences in regions, and its rates were standardized with sex and age of population in the regions. The Korean Statistical Information Service (KOSIS) and Community Health Survey (CHS) were used to identify the regional variables in 2009. Ordinal Least Square (OLS) regression and Geographically Weighted Regression (GWR) were applied to identify their effects. Statistical analysis was performed by using SAS ver. 9.3, and ArcGIS ver. 10.0 was used for spatial analysis. Results: OLS results showed that the number of basic livelihood recipients per 100,000 population and the proportion of elderly population had significant positive relationships with the standardized CAP patients per 100,000 population. Results from GWR showed that the directions of coefficients were varied depending on regions. Conclusion: This study identified that social·economical·welfare status of the regions may not have consistent effects on the occurrences of CAP. Further studies will be needed with the additional variables representing regional characteristics.