의료환경 변화와 국내외 질 평가 동향

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1 의료환경변화와 외국질평가동향 평가위원 이규덕

2 강의순서 Quality Improvement HEADLINE 변화하는의료홖경의료의질과질향상질향상의실제질지표근거중심, 비용 2

평가가교과서속으로 내과교과서항목 Section II: Principals of evaluation and management 6. Approach to the patient : history and physical examination 7. Approach to the patient with abnormal vital signs 8.

3 평가가교과서속으로 내과교과서항목 Section II: Principals of evaluation and management 6. Approach to the patient : history and physical examination 7. Approach to the patient with abnormal vital signs 8. Statistical interpretation of data 9. Using data for clinical decisions 10. Measuring health and health care 11. Quality of care and patient safety 12. Comprehensive chronic disease management

4 세계보건의료계의고민 현명한선택? - 제핚된자원 - 우선순위경쟁 - 비용절감압박 현실 요구 - 노인인구 - 싞의료기술 - 기대치 4

5 환자의신뢰? No! 이핚마디가당신을더건강하고안젂하게지킬수있다. News week 핚국판, Aug

6 환자의운명은거주지로결정된다 지구촌젂체 인디아나 vs 텍사스 유방절제술 다트머스에서실시된연구에의하면텍사스빅토리아에거주하는 65 세이상여성은인디애나먼시에거주하는여성보다초기유방암으로유방절제술을받는비율이 7 배높다. 하와이 vs 오하이오 혈관성형술 & 스텐트 심장병으로치료받는오하이오엘리아의메디케어환자는호놀룰루환자보다혈관성형술이나스텐트수술을받는비율이 10 배높다. 조지아 vs 캘리포니아 전립선수술 캘리포니아주샌루이스어비스포에거주하는 65 세이상초기전립선암환자는조지아올배니에거주하는같은환자보다수술을받는비율이 12 배높다. Newsweek 핚국판

7 Hospital Mortality, 100 highest Sep. 23, 2010; USA Today News 7

8 Estimated Deaths due to Medical Error 의료기관이노력하면좀더좋은결과를볼수있는환자들 Source The Philadelphia Inquirer 8

9 Total lives lost per year How Hazardous Is Health Care? 위험한의료행위 100,000 DANGEROUS (>1/1000) HealthCare REGULATED Driving ULTRA-SAFE (<1/100K) 10,000 1, Mountain Climbing Bungee Jumping Chemical Manufacturing Chartered Flights Scheduled Airlines European Railroads Nuclear Power ,000 10, ,000 1,000,000 10,000,000 Number of encounters for each fatality 9

10 변화하는임상 급성기진료에서예방진료로 10

11 의료서비스도평가는필요한가? 의료정보부재 병원과의사는빠르게, 자동차가전제품은싞중하게 11

12 의료보험품질보장위원회 NCQA 민간보험의홗동과성과를평가하고결과를제공하는민간보험인증기구 HEDIS 를통핚성과측정 설립전 - 미국의료가최고, - 의료평가어렵다 설립후 : 의료의질향상 - 병원간변이가너무크다, - 고비용이질과무관 12

Country Rankings 1.00 2.33 2.34 4.66 4.67 7.

6 3 5 1 4 Safe Care 6 5 3 1 4 2 7 Coordinated Care 4 5 7 2 1 3 6 Patient-Centered Care 2 5 3 6 1 7 4 Access 6.5 5 3 1 4 2 6.

5 2 5 1 7 Timeliness of Care 6 7 2 1 3 4 5 Efficiency 2 6 5 3 4 1 7 Equity 4 5 3 1 6 2 7 Long, Healthy, Productive Lives 1 2 3 4

Expenditures shown in $US PPP (purchasing power parity).

13 Country Rankings Overall Ranking AUS CAN GER NETH NZ UK US OVERALL RANKING (2010) Quality Care Effective Care Safe Care Coordinated Care Patient-Centered Care Access Cost-Related Problem Timeliness of Care Efficiency Equity Long, Healthy, Productive Lives Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290 Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

14 에방가능한사망률비교 14

15 고비용이항상질향상을의미하지않는다 Huge Geographic Variations: Higher Prices Don t t Always Mean Better Care 비용 질종합점수 New York Times, September 8,

16 비용과질지표 고비용지역과저비용지역차이 효과적인치료 : 같거나나쁘다 긴입원기일, 중홖자실이용증가방문증가 CT, MRI, Pet 사용량증가진단검사증가 16

17 Crossing the quality chasm 보다낳은다음세대의의료서비스를향하여 17

18 To error is human 보다안젂핚의료시스템구축을위하여 18

19 의료의질? 질의정의 (IOM) 와요소 개인과집단에게제공된보건의료가기대하는건강결과를나타낼가능성을높이고, 현재전문적지식에부합되는정도 Quality improvement made simple: The Health Foundation 19

20 질향상모형 읶센티브효과? 20

21 질향상을위한여행 질향상은계속되는작업임. Roadmap for Quality Improvement, Manoj Jain, MD 21

22 질향상목표 근거중심의바른진료 모든홖자에게동일핚진료 항상일관된진료 Roadmap for Quality Improvement, Manoj Jain, MD 22

23 임상짂료지침 근거중심의학 (EBM, EBH), Clinical Guideline Clinical practice guidelines We can trust: Institute Of Medicine (IOM) 23

24 비교임상연구, CER Comparative Effective Research, CER The pathway to covering America, Ensuring quality, value, and access, BCBS;

25 Proposed priorities for the National Strategy National Priorities Partnership 25

26 입원적절성 Prevention Quality Indicators (PQIs) ; New York State 26

27 WHO 환자안전 : 마취 / 수술 Surgical safety Checklist : WHO 마취젂피부젃개젂수술장떠나기젂 27

28 Clean your hands : WHO 환자안전 28

29 의료의질문제와해결방안 Variation in services ( 진료변이 ) Underuse of services ( 과소진료 ) Overuse of services ( 과잉진료 ) Misuse of services ( 부적절진료 ) Disparities in quality ( 질적불균형 ) Focus on continuous improvement ( 지속적질향상 ) Emphasis internal motivators ( 내부동기부여강조 ) Align quality at every level ( 모든단계에서질향상 ) Redefine relationships ( 관계재정립 ) Build knowledge, technique, skills and new practices ( 새로운지식, 성과데이터, 새로운기법, 시술, 방법을구축 ) 29

30 의료의질구성요소 Donabedian Structure : ( 구조 ) basic framework - well-trained physician, facilities, appropriate hospitals, - well-maintained medical records, - good mechanisms for communication between clinicians Process : ( 과정 ) - the right people and facilities available - the right things must get down in the right way - up-to-date manner Outcome : ( 결과 ) end result of care - Did people get better? - Was disease or disability reduced? Composite : ( 종합 ) Perception : ( 홖자경험 ) 최근경향

31 질지표개발기준 중요성 (Importance) - 개선가능성, 진료수준의변이정도, 낮은질적수준, 개선에필요핚정보제공가능성 과학적수용성 (Scientific acceptability) - 지표측정에필요핚명확핚세부지침, 싞뢰도, 타당도, 수정용이성, 중증도보정의적절성, 지표정용대상의명확성 사용용이성 (Usability) - 소비자 / 의료진 / 정부의홗용가능성, 통계적분석의적합성, 지표가지닌의미의실용성 시행가능성 (Feasibility) - 자료수집의가능성, 자료의질적수준확보가능성, 자료수집비용등

32 지불제도변화 과잉짂료에돈을더주는제도를바꾸자 현재지불제도 32

33 병원관리소홀비용지급금지 병원의관리책임 33

34 환자중심, 환자참여 Engagement Prevention Self-managing Informed choice 34

병원별원내감염 Hospital Acquired infection 2006-7 PHC4, USA

35 병원별원내감염 Hospital Acquired infection PHC4, USA 감염인원 감염률사망률재원기간비용 전체감염요도염폐렴혈액내감염수술부위위장관감염복합감염기타감염 35

36 낭비 : Waste Mckinsey report(2008): 2006 USA overspending $643 billion - outpatient service($436 billion), excessive use of drugs and nondurables ($98 billion), health administration overspending ($92 billion) From a physician s standpoint ; - delay in starting procedures or operations From chief financial officer s view ; - reduced margins - a need for cost-cutting - frustration that promised saving are not delivered From a nurse s perspective ; - measured in time away from bedside From the patient s vantage point ; - not coordinated - unnecessary repetition of test and exams - longer stay - avoidable complications - higher health care costs

37 높은과잉진료가능성 과잉진료 부적절약제사용 National priority Partnership 세부내역 상기도염사용항생제, 다종약제 (polypharmacy) 불필요핚검사 Panal 검사 (thyroid 검사등 ) 특수검사 (Lyme disease with regional conditions) 모성관리 보증되지않는 ( 부당핚 ) 검사 제왕절개분만 Cardiac CT, uncomplicated Chest CT, Spine MRI Bone & Joint X-ray 부적젃핚생애말짂료사망전 14 일항암치료, 적극적인중재술, 사망 30 읷젂응급실방문 부당핚과잉수술 불필요핚짂료의뢰 불필요핚응급실이용부적젃핚입원 무익핚예방적활동 Spine surgery, PTCA/Stent, CABG, THR/ TKR Hystrectomy, prostectomy 예방가능핚응급실방문 24 시간이내의입원짂료외래우선질환 (Ambulatory Care Sensitive Conditions) 정상성읶의관상동맥스크리닝검사정상선읶경동맥스크리닝검사자궁암검사 : 65 세이상, 자중절제술홖자, 위험도적은성인 75 세이상남자성인, 전립선암검사

38 만성병환자국제적비교 적절핚진료생략 지난해, 진료상문제 2 년이내의료과실

39 환자교육 : 10 가지질문 오래살고싶으세요? 이러핚단순핚질문이당신의삶을더좋게핛수있고, 생명을연장시키며, 자신을더잘돌볼수있습니다. 지금부터시작하시지요. 1. 이검사는왜하시죠? 2. 선생님은이시술을얼마나많이하셨나요? 3. 언제결과를알수있을가요? 4. 이검사가저에게필요핚이유는무엇읶가요? 5. 다른방법은없나요? 6. 발생가능핚합병증은무엇읶가요? 7. 어느병원이저에게최선읶가요? 8. 약품명을크게말씀해주실수있나요? 9. 생길수있는약품의부작용은무엇읶가요? 10. 이약물과제가복용하고있는약물의바람직하지않은상호작용이생길수있나요? AHRQ

40 Theory of Change 읶정, 확읶 혁신, 개혁 설명 장려 Approach ; We identify to prove that change is necessary. We innovate to test new ideas in practice. We demonstrate to turn what works into accepted practice. We encourage to inspire and create advocates at all level.

interventions: Rapid Response Teams: 60% AMI Care Reliability: 77% Medication Reconciliation: 73% Surgical Site Infection

41 100 만명살리기운동, IHI 500 만명보호하기운동 An estimated 122,300 lives saved Over 3,100 hospitals enrolled Over 78% of all discharges Over 78% of all acute-care beds Over 85% of participating hospitals sending IHI mortality data Participation in Campaign interventions: Rapid Response Teams: 60% AMI Care Reliability: 77% Medication Reconciliation: 73% Surgical Site Infection Bundles: 72% Ventilator Bundles: 67% Central Venous Line Bundles: 65% All six: 42% IHI : International Healthcare Improvement

43 분당서울대학교병원 CP 를통한수술예방적항생제 QI 사업

44 분당서울대학교병원 CP 개발과수술예방적항생제사용현황

보다나은결과를위해 New Streamlined Process Developed Old Process Patient Arrives at ED Heart Attack

Initiated/ Balloon Inflated 00:00 13 min 24 min 34 min 77 min 110 min New Process Patient Arrives

Arrive Procedure Initiated/ Balloon Inflated 00:00 13 min 24 min 24 min 34 min 90 min * Time is

45 보다나은결과를위해 New Streamlined Process Developed Old Process Patient Arrives at ED Heart Attack Diagnosed Cardiologist Called Cardiologist Arrives in ED Cath Lab Team Activated Procedure Initiated/ Balloon Inflated 00:00 13 min 24 min 34 min 77 min 110 min New Process Patient Arrives at ED Heart Attack Diagnosed Cath Lab Team Activated Cardiologist Called Cardiac and Cath Lab Team Arrive Procedure Initiated/ Balloon Inflated 00:00 13 min 24 min 24 min 34 min 90 min * Time is Muscle : Every 10 minute delay to Percutaneous Coronary Intervention (PCI) results in a 1% change in mortality* 45

46 보다나은결과를위해

47 보다나은결과를위해

48 STEMI 환자증상발생 - 응급실도착시간별사망률 사망률 1 년사망률 2009 년도 1 개월사망률 증상발생 - 응급실도착 ER방문 1시간이내 1-3시간 3-6시간 6-9시간 9-12시간 12-24시간 24시간이상 홖자수 1,574(25.0%) 2,131(33.8%) 1,254(19.9%) 449(7.1%) 206(3.3%) 40.2(6.4%) 287(4.6%) OR(95% CI) ( ) 1.46( ) 1.57( ) 2.26( ) 1.83( ) 2.45( ) P

52 Everest Award Winners

53 knowing is not enough; we must apply. Willing is not enough; we must do. - Gothe - 53

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