PSJHJOBM! BSUJDMF 대한족부족관절학회지 : 제 15 권제 3 호 2011 J Korean Foot Ankle Soc. Vol. 15. No. 3. pp.165-169, 2011 당뇨병성족부질환자의직접의료비용분석 아주대학교병원가정간호센터 *, 연세대학교의과대학정형외과학교실, 아주대학교의과대학정형외과학교실 송종례 * 이진우 한승환 Analysis of Direct Service Costs about Diabetic Foot Patients Chong Rye Song, R.N., Ph.D., * Jin Woo Lee, M.D., Ph.D., Seung Hwan Han, M.D., Ph.D. Home Care Services Center, Ajou University Hospital, Suwon, Korea * Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Korea =Abstract= Purpose: The objective of this study was to analyze diabetic foot patients direct service costs until the cure of the disease. Materials Methods: The subjects of this study were randomly sampled 60 patients who had been treated for diabetic foot at one of two tertiary hospitals and cured of the disease during from January 2008 to December 2009, and whose diagnostic code was E11.5 or E14.5. Data were collected from medical records and direct service costs were analyzed using data on the payments of individual service charges. Direct service costs spent at other medical institutions for the same disease were excluded. Collected data were analyzed using descriptive statistics. Results: The subjects mean hospital stay was 29 days, and mean period until cure was 132 days. The inpatient cost per patient was 10,844,648 won, outpatient cost was 715,751 won, and home care services cost was 641,854 won, so total direct service cost per patient was 11,913,419 won. The total direct service cost in patients who had their foot amputated was 12,769,822 won, 1.3 times higher than without amputation, who had vascular intervention was 16,219,477 won, 1.9 times higher than non vascular intervention, who had both infection and artery occlusion was 17,522,435 won, 2.0 times higher than either infection or artery occlusion. Conclusion: In diabetic foot patients, the direct service cost was highest as 17,522,435 won in patients accompanied with both infection and occlusion of lower extremity artery. Key Words: Diabetic foot, Direct service costs 서 론 전세계적으로당뇨병환자는급증하고있으며 2007 년 Received: July 30, 2011 Revised: August 10, 2011 Accepted: August 16, 2011 Seung Hwan Han, M.D., Ph.D. Department of Orthopedic Surgery, Ajou University School of Medicine, San 5 Woncheon-dong, Yeongtong-gu, Suwon 443-721, Korea Tel: +82-31-219-5520 Fax: +82-31-219-5529 E-mail: osmedic@ajou.ac.kr OECD국가에서당뇨병과합병증치료와예방에약 2,120 억달러가소요되었다. 1) 1995년대비 2005년당뇨병진단환자수는 3배, 연도별총진료비는 8배증가하였으며, 2003년전체성인의건강보험총진료비의 19.2% 를차지하였다. 2) Chung 등 3) 의연구에서 2003년건강보험청구환자의당뇨병성족부질환의 1인당연간평균총진료비는족부절단 1,162만원, 족부궤양 780만원으로비당뇨환자에비하여각각 2.0배 1.7배많았다. 2001년미국에서당뇨병성족부궤양과족부절단으로인한보험지불비용은 109억달러였 - 165 -
송종례 이진우 한승환 으며, 같은해영국에서의당뇨병관련전체국가지불비용의 5% 를차지하였고, 당뇨병성족부질환관련비용은 2억5 천2백만파운드였다. 4) 당뇨병성족부질환에대한비용은많은경우완전히완치되기까지추적되지않고, 단지수술단계중심으로조사되었기때문에과소추정되었다고볼수있으며, 정확한비용을얻기위해서는질환의발견부터최종적인결과 ( 치유나사망 ) 에이르기까지진료, 치료, 입원, 지속적인관리및재활에이르기까지모든비용이조사되어야한다. 5) 국내당뇨병성족부질환에대한직접의료비용연구는질환의완치시까지조사하지않고 1년간치료비용을조사한것으로질환의완치시까지소요된직접의료비용에대한국내연구자료가부족한실정이다. 3,6) 이에본연구는당뇨병성족부질환의완치시까지소요되는직접의료비용을산출하고치료유형에따른직접의료비용을비교해보고자한다. 1. 연구설계 대상및방법 본연구는당뇨병성족부질환의완치시까지소요된입원및응급진료비, 외래진료비, 가정간호비에대한환자부담금과보험자부담금을합한직접의료비용을조사하기위하여의무기록조사와개인별진료비수납자료를이용하여자료를분석하는후향적조사연구이다. 2. 연구대상 연구대상은 2개상급종합병원에서 2008년 1월에서 2009 년 12월까지당뇨병성족부질환을주요문제로입원및외래진료를받은환자중편의추출한 60명이다. 대상자선정은의무기록데이터베이스에서진단코드가 E11.5 또는 E14.5로등록된환자중에서만 20세이상인 2형당뇨환자로서 1년이내당뇨병성족부질환이완치된자로하였으며, 입원중내외과적인중증질환치료를병행한자는제외하였다. 3. 연구방법 연구대상자의특성과질환및치료관련내용은의무기록조사 ( 또는전자의무기록 ) 를통하여수집하였다. 또한연구대상자의입원및응급진료에대한기간및횟수, 외래진료일과가정간호이용에따른방문일은의무기록조사를기본 으로하고자료조사의효율성과정확도를위하여진료정보시스템을병행하여조사하였다. 직접의료비용은전체진료비수납자료중에서진료내역조회와의무기록조사를상세하게검토하여내외과적문제로소요된비용을제외하고당뇨병성족부질환을주요문제로치료한경우만을포함하여계산하였다. 족부질환완치이후새로발생한족부질환치료비용과정기적인상태관찰을위해외래진료를본경우는제외하였고응급진료비는별도로분리하지않고입원진료비에포함하여분석하였다. 외래진료비에서경구복용약등의원외처방에대한약제비와원외약국의조제료는경구약처방빈도가낮고내과처방약과별도로분리가어려워조사항목에서제외하였다. 당뇨병성족부질환의완치시까지의진료비용조사시 2008 년부터 2009년사이에치료를받은환자를대상으로하였기때문에매년건강보험수가가인상됨에따라연도별로진료비차이가발생하여진료비용은 2009년기준으로보정하였다. 즉 2009년행위료등에대한환산지수는 2008년에비해서 2% 인상되었기때문에 2008년치료대상자의비용은기본진료료, 처치및수술료등의행위별수가에대해 2% 를가산하여계산하였다. 당뇨병성족부질환의특성상타의료기관에서치료중전원되어온경우와퇴원후다시타의료기관에서치료를받은경우이에대한진료비용은자료수집이어려워제외하였다. 수집된자료는대상자의특성, 치료현황및진료비항목별진료비용에대해빈도와백분율표시하였다. 절단유무, 혈관중재시술유무등에따른직접의료비용은평균과표준편차를이용하여비교하였다. 결과 1. 연구대상자의특성및치료현황대상자의성별분포는남자가 61.7% 로많았으며, 나이는평균 63.5세로 60세이상이 63.3% 를차지하였다. 당화혈색소는평균 8.7% 로 8.1% 이상이대상자의 58.6% 를차지하였고, 2형당뇨병진단기간은평균 16.7년으로 11년이상이 63.3% 를차지하였다. 평균입원일은 29일로 2회이상입원이 21.6% 이었으며, 평균질환완치기간은 132일이었다. 입원전타의료기관외래진료나입원이 48.2% 이었으며, 퇴원후가정간호연계가 55.0%, 타의료기관외래진료연계나재입원이 28.4% 를차지하였다. 족부궤양의중증도에서족부감염만있는경우는 53.3%, 허혈만있는경우 11.7%, 감염과허혈이동반된경우가 35.0% 로나타났다. 절단수술횟수는 1회 53.3%, 2회이상 20.0% 였으며, 혈관중재시술횟수 - 166 -
당뇨병성족부질환자의직접의료비용분석 는 1회 26.7%, 2회 16.6% 를차지하였다. 2. 직접의료비용의분포당뇨병성족부질환의완치시소요되는직접의료비용은 1인당평균 11,913,419원으로이중입원진료비가 91% 를차지하며 1인당평균입원진료비는 10,844,648원이었으며, 외래진료비는 9% 를차지하며 1인당평균외래진료비는 715,751원이었다 (Table 1). 입원진료비중투약및주사료가 25%, 수술료및처치료가 20%, 입원료 ( 입원관리료및병실료 ) 가 19% 를차지하였다 (Fig. 1). 진료비항목별비용을살펴보면 Table 2와같다. 입원진료비중 1인당평균투약및주사료는 2,664,348원, 입원료는 2,030,011원, 수술료및처치료는 2,131,883원, 진단검사의학검사비는 1,095,829원순으로나타났다. 외래진료비중에서는 1인당평균 MRI, PET-CT검사비는 579,927 원, CT검사비는 310,405원으로진료비항목중에서가장높았으며, 외래진찰료는 1인당평균 127,496원, 치료재료비는 109,317원이었다. 가정간호비는 1인당평균기본방문료및교통비가 446,489원으로나타났다. 입원 1일당입원진료비는 1인당평균 408,574원이며, 외래진료 1회당 1인 당평균진료비는 86,648원, 가정방문 1회당 1인당평균비용은 43,242원이었다. 3. 치료내용에따른직접의료비용족부절단환자의 1인당평균직접의료비용은 12,769,822 원으로비절단환자에비하여 1.3배높았다. 혈관중재시술환자는 16,219,477원으로혈관중재비시술환자에비하여 1.9배높았다. 감염과동맥혈관의폐쇄가동시에동반된경우 17,522,435원으로감염또는동맥혈관의폐쇄중한가지문제만가진환자에비해 2.0배가높았다 (Table 3). 고찰당뇨병성족부질환의완치기간은평균 11~14주로보고되고있으나본연구에서는평균 18주로나타나연구대상자모두감염또는허혈성궤양이있는점에서완치기간이길수있다. 4,5) 또한연구대상자선정과정에서 1년이상족부질환이완치되지않아서대상자에서탈락된경우가적지않았고 1년이내완치된환자를대상으로하였기때문에실제평균완치기간은더길게나타날수있을것이나이는 Meals 4% MRI etc 6% Anesthesia 2% Others 1% Drug Radiology 25% 6% Materials 7% Laboratory 10% Inpatient fee 19% Treat & OP 20% Figure 1. Distribution of inpatient costs for diabetic foot; MRI etc, sum of magnetic resonance imaging fee, positron emission tomography computed tomography fee and ultrasonography fee; Others, sum of transfusion fee, rehabilitation fee and psychology consultation fee; Treat & OP, treatment & operation fee. Table 1. Medical Costs per Patient and Sum according to Categories (Unit: Won) Categories Costs per patient Sum of costs Mean (SD) n cost (%) Inpatient costs 10,844,648 (7,065,199) 60 650,678,858 (91.0) Outpatient costs 715,751 (587,474) 60 42,945,082 (9.0) Home care services costs 641,854 (496,788) 33 21,181,171 (3.0) Total insurer's paid costs 7,052,528 (4,909,267) 60 423,151,694 (59.2) Total patient paid costs 4,860,890 (2,693,681) 60 291,653,418 (40.8) Total medical costs 11,913,419 (7,163,409) 60 714,805,111 (100.0) SD, standard deviation. - 167 -
송종례 이진우 한승환 Table 2. Medical Costs per Patient according to Item (Unit: Won) Item Inpatient costs Outpatient costs Home care services costs n Mean (SD) n Mean (SD) n Mean (SD) Doctor's fee 60 56,428 (32,257) 60 127,496 (94,329) 33 446,489 (343,762) * Inpatient fee 60 2,030,011 (1,359,510) Meals fee 60 438,500 (312,377) Drug fee 60 2,664,348 (1,837,938) 39 205,911 (275,647) 10 119,610 (93,316) Anesthesia fee 51 295,614 (237,649) Treat & OP fee 60 2,131,883 (2,471,917) 33 104,818 (86,821) Laboratory 60 1,095,829 (863,153) 45 96,672 (101,084) 7 27,161 (30,891) Radiology 60 679,067 (692,619) 40 70,158 (130,833) Material fee 60 740,340 (1,228,685) 56 109,317 (107,064) 32 50,056 (49,286) CT 26 399,347 (165,525) 9 310,405 (15,846) MRI, PET-CT 23 779,546 (235,256) 3 579,927 (229,983) Ultrasonography 35 267,094 (218,358) 8 135,875 (134,214) Others 31 162,717 (290,148) 11 36,337 (56,988) * Visiting & traffic fee; Treat & OP fee, treatment & operation fee; CT, computed tomography; MRI, PET-CT, Magnetic resonance imaging, Positron Emission Tomography-computed tomography; SD, standard deviation. Table 3. Comparison of Costs according to Treatment and Severity (Unit: Won) Categories Yes No n Mean (SD) n Mean (SD) Amputation 16 12,769,822 (7,814,103) 44 9,558,308 (4,327,795) Restricted antibiotics use 28 13,605,302 (6,672,921) 32 10,433,021 (7,350,706) Vascular intervention 26 16,219,477 (7,733,796) 34 8,620,551 (4,544,409) Infection & ischemic foot * 21 17,522,435 (5,510,992) 39 8,893,179 (6,077,777) * Comparison of costs between combined infection and ischemic and infection or ischemic only groups; SD, standard deviation. 연구대상기관이상급종합병원이기때문에대상자의중증도가높기때문인것으로생각된다. Holzer 등 7) 의연구에서입원비용이 80% 이상을차지하였으며, Boulton 등 4) 에서는비절단족부궤양치료의경우입원비가전체진료비의 37% 인반면, 족부절단의경우입원비가 65% 로차이가있는점은족부궤양의경우퇴원후궤양치료뿐만아니라재발한경우는사회복지서비스및가정간호등 ( 진료를위한이송교통비, 가정내환경개선, 식사와청소서비스등 ) 에많은비용이소요되었기때문으로전체의료비용의범위에따라입원비용의비중이다르게나타남을알수있다. 본연구에서는교통비, 간병비등의간접의료비가제외된직접의료비용만을산출한것으로입원전과퇴원후의타의료기관의진료비용도제외되었기때문에직접의료비용중입원진료비용이 90% 로높게나타난것으로생각된다. 족부절단수술환자의 1인당평균직접의료비용은 12,769,822 원, 비수술환자는 9,558,308원인점에서 2003년건강보험청구환자의당뇨병성족부질환의 1인당연간평균총진료비는족부절단 1,162만원, 족부궤양 780만원이며, 3) Hwang 등 6) 의 3차의료기관제2 형당뇨환자의비용연구에서당뇨병성족부질환으로하지절단을받는경우가 13,960,314원으로나타나비용산출단위와연도별수가상승을고려할때유사함을알수있다. 혈관중재시술군은혈관중재시술을안한환자에비하여직접의료비용이 1.9배로나타난점은 Stockl 등 8) 의연구에서혈관이부적절한경우는 23,372달러, 혈관에문제가없는경우는 5,218달러로나타난점과유사하였다. 또한하지동맥폐쇄로인한혈관중재시술환자가족부절단환자에비하여직접의료비용이높은점은건강보험수가에서수족절단에대한수술료는 139,930원인데비하여경피적혈관내금속스텐트삽입술의경우 514,970원 9) 으로높고시술은 1개이상의혈관에시술이이루어지고, 시술에소요되는재료대의경우수백만원에이르며시술전고가의진단검사가이루어지기때문이다. 본연구는상급종합병원에서치료받은당뇨병성족부질환자를대상으로하였기때문에일반화하는데제한점이있다. 그러나 Park 등 10) 의연구에서당뇨병상병코드를주- 부상병으로청구된건강보험급여청구자료의입원환자진 - 168 -
당뇨병성족부질환자의직접의료비용분석 단타당도는 87.2%, 외래환자진단타당도는 72.3% 인점에서건강보험급여청구진단명이아닌의무기록상최종진단명으로의무기록조사를실시하여치료내용을확인하고비급여대상진료비를포함한직접의료비용을계산하였기때문에당뇨병성족부질환의직접의료비용을분석함에있어서유용한자료로활용될수있다. 또한당뇨병성족부질환의직접의료비용이연간단위가아닌질환의완치시까지소요된비용연구라는측면에서관련연구에유용한기초자료로활용될수있으나타의료기관에서의진료비용이제외된점은연구의제한점이다. 결론본연구는의무기록조사를병행하여조사함으로써당뇨병성족부질환자의질환의완치시까지의실질적인직접의료비용산출에연구의의의가있다. 질환의완치시까지의 1인당평균직접의료비용은 11,913,419원이었으며, 감염과하지혈관의폐쇄가동반된경우 17,522,435원으로가장높았으며, 단일요인으로는혈관중재시술환자가 16,219,477 원으로가장높았다. REFERENCES 1. OECD Korea Policy Centre. Health at a Glance 2009: OECD INDICATORS, OECD Korea Policy Centre Health and Social Policy Programme. 2010. 200. 2. Basic Statistics Diabetes Task Force Team. Basic statistics on diabetes Task Force Team report: Diabetes in Korea 2007. Korean Diabetes Association & Health Insurance Review & Assessment Service 2007. 74. 3. Chung CH, Kim DJ, Kim JY, et al. Current status of diabetic foot in Korean patients using national health insurance database. J Korean Diabetes Assoc. 2006;30:372-6. 4. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366: 1719-24. 5. Apelqvist J, Larsson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev. 2000;16 Suppl 1:S75-83. 6. Hwang JA, Park TC, Jung SH, et al. Direct medical costs of type 2 diabetic patients in the tertiary hospital. Korean Diabetes J. 2008;32:259-68. 7. Holzer SE, Camerota A, Martens L, Cuerdon T, Crystal-Peters J, Zagari M. Costs and duration of care for lower extremity ulcers in patients with diabetes. Clin Ther. 1998;20:169-81. 8. Stockl K, Vanderplas A, Tafesse E, Chang E. Costs of lower-extremity ulcers among patients with diabetes. Diabetes Care. 2004;27:2129-34. 9. Korea Hospital Association. National Insurance Claim Guide Book. 2010. 688. 10. Park IB, Kim DJ, Kim JY, et al. - The report of epidemiological study for diabetic diseases- focus on Diabetes in Korea 2007. Clinical Diabetes. 2007;8:356-60. - 169 -