한국임상약학회지제 26 권제 2 호 Korean J Clin Pharm, Vol. 26, No. 2, 2016 Original Article Korean Journal of Clinical Pharmacy Official Journal of Korean College of Clinical Pharmacy Available online at http://www.kccp.or.kr pissn: 1226-6051 만성질환자의상용치료원이용과복약순응도간의관계 정연 1 변진옥 2 * 1 서울대학교보건환경연구소, 2 국민건강보험공단건강보험정책연구원 (2016년 1월 18일접수 2016년 6월 6일수정 2016년 6월 7일승인 ) The Association between having a Usual Source of Care and Adherence to Medicines in Patients with Chronic Diseases Youn Jung 1 and Jinok Byeon 2 * 1 Institute of Health and Environment, Seoul National University, Seoul 08826, Republic of Korea 2 Health Insurance Policy Research Institute, National Health Insurance Service, Wonjoo 26464, Republic of Korea (Received January 18 2016 Revised June 6 2016 Accepted June 7 2016) ABSTRACT Objective: This study was to explore the association between having a usual source of care and adherence to medicines in patient with chronic diseases. Methods: The 2012 Korea Health Panel was used as a data source. We analyzed 4,418 respondents that were diagnosed with chronic diseases and utilized health care services. Non-adherence to medication, a dependent variable, was defined as not taking the medicines that were prescribed for treating chronic disease or not following the direction for medication. Whether having a usual source of care or not was used as a key independent variable, which was defined as having a regular site or a regular doctor for medical test, treatment, and consultation. Sex, age, education level, marital status, income, the type of health insurance, the number of chronic disease and CCI (Charlson Comorbidity Index) were included as covariates in the analysis. We conducted a multivariate logistic regression. Results: Totally, 30 percent of respondents reported to experience nonadherence to medication. Having a usual source of care was significantly associated with lower non-adherence to medication regardless its type, which is a regular doctor (OR=0.61, 95% CI=0.53-0.70) or a regular site (OR=0.67, 95% CI=0.58-0.78). Furthermore, having a usual source of care was associated with both of medication persistence (OR=0.66, 95% CI=0.54-0.81) and compliance (OR=0.65, 95% CI=0.56-0.76). Conclusion: Our results showed the possibility that usual source of care is able to conduct a positive role in improving adherence to medication with better management of chronic disease. KEY WORDS: Adherence to medication, usual source of care, chronic disease, medication persistence, medication compliance 생활습관의변화와더불어인구고령화가빠르게진행되면서만성질환을앓고있는사람들의숫자도급격하게증가하고있다. 한국의대표적만성질환인고혈압과당뇨병의유병률은 2011년기준각각 31%, 11% 로높은수준을유지하고있으며, 이로인해지출되는건강보험진료비가각각전체건강보험재정의 1위와 3위를차지하고있다. 1) WHO (2010) 통계에따르면, 만성질환은전세계적으로장애와사망의주요원인으로작용하고있으며, 세계인구의약 60% 가만성질환으로사망하는것으로나타났다. 2) 만성질환의경우발병하면완치가어렵기때문에꾸준한관 리와치료가중요하다. 특히, 오랜기간약물관리가필요한경우가많으며환자들도이들질환에대한의약품복용여부를치료여부의기준으로판단한다. 3) 따라서이러한만성질환자의치료에있어의료적필요에적합한의약품복용이중요한데, 이는의사의처방전을조제하여 (filling prescriptions) 계속복용하는것 (persistence) 과지시한용량및용법대로복용하는것 (compliance) 을모두포함하는것으로의약품복약순응을의미한다. 4) 의약품을지시대로복용하지않을경우질병이제대로치료되지않거나합병증발생으로이어질수있으며, 5) 의약품내성발생의원인이되기도한다. 또한이러한건강상 *Correspondence to: Jinok Byeon, Health Insurance Policy Research Institute, National Health Insurance Service, 32 Sambo-ro, Wonjoo, Kangwon 26464, Republic of Korea Tel: +82-10-9040-6260, Fax: +82-2-3275-8063 E-mail: byeonjo@nhis.or.kr 128
만성질환자의상용치료원이용과복약순응도간의관계 / 129 태의악화는입원비용증가에직접적인영향을미치는것으로보고되었다. 6) 이렇듯의약품복약순응은환자의건강결과는물론이고의료비를비롯한사회적비용에도영향을미친다는점에서그중요성이크다. 하지만오랫동안약물복용을지속해야하는만성질환자들에게서복약불순응문제가자주발생하고있다. 국내선행연구결과에따르면, 고혈압의경우복약순응군의비율이 47.7% 에서 57.4% 에이르는것으로보고되었고, 7,8) 당뇨의경우에는 29.4% 로파악되었다. 9) 이러한낮은복약순응혹은복약불순응은그것이자발적으로이루어졌든, 혹은비자발적이든간에, 의사가객관적으로판단한의료적필요를제대로충족하지못했다는점에서일종의의약품이용에서의미충족니드 (unmet health care needs) 와연계될수있다. 미충족의료란의료인혹은환자개인이판단한의료적필요를적절한의료이용을통해충족시키지못한것을의미하는데, 좁게는보건의료서비스에대한접근성에서넓게는제공된의료서비스가기능상태의개선에도움을주었느냐의여부로이를정의한다. 10) 그리고복약불순응을이러한미충족의료와연결시켜바라볼경우, 복약불순응은단순히개인의행태차원의문제에그치지않고보건의료시스템상의접근이필요한문제로접근할수있으며, 허순임과이수형 (2011) 역시고혈압환자와당뇨병환자의의약품미복용을미충족의료로정의하여분석한바있다. 3) 그러나지금까지우리나라에서이루어진복약순응도에대한연구들은주로개인의인구학적, 혹은사회경제적요인, 질병특성등과같은요인에대한분석에집중되어있어, 개인의요인을넘어선의료공급자요인및제도적요인이복약순응에어떠한영향을미치는지에대해서는알기어려웠다. 더욱이많은연구들이일부만성질환이나노인집단, 일개병원의환자들만을대상으로하여우리나라만성질환환자들전반의양상을파악하고함의를끌어내기어려운측면이있었다. 9,11-13) 예를들어노인당뇨환자의복약순응도에영향을미치는요인을분석한이의경등 (2000) 에따르면처방기간, 의약품복용횟수와처방의약품수, 처방변경정도, 복약방법에대한이해도와환자의학력이복약순응도에유의한영향을미치는것으로나타났다. 12) 또한환자조사방식을통해고혈압과당뇨병노인의복약순응도를분석한김성옥 (2011) 의연구에서는환자의노동참여, 교육수준, 민간보험가입여부, 의약품개수, 1일의약품복용회수, 약사의설명, 약값으로인한복약불순응의경험여부가복약순응도에영향을미치는것으로나타났다. 11) 이와함께, 복약순응도에대해분석한기존의연구들은복약방법을제대로따르고있는지여부에만초점을맞춘경우가많았다. 5,11-13) 다시말해, 아예처방전을조제하지않거나약을계속해서복용하지않는경우에대한분석은복약순응도연구에서배제되어왔다. 이러한기존연구의한계들을반영하여본연구에서는복약 순응도를단순한복약지시준수가아닌복약지속까지를포함한개념으로확장하여만성질환환자들의의약품이용을증진시키기위한함의를제공하고자한다. 또한의약품이용에영향을미칠수있는여러요인들중상용치료원 (usual source of care) 의역할에주목하고자한다. 상용치료원이란아프거나의학적조언이필요할때일정하게방문하는보건의료공급자또는장소로정의되며, 특정의료기관과더불어특정공급자 ( 보건의료인 ) 를포함하는개념으로사용된다. 14) 꾸준한관리와치료가중요한만성질환에서는의사와환자간의신뢰와협력관계가무엇보다중요하다. 일상적인결정과행동들이만성질환을잘관리하여건강을유지하는데도움이되도록환자들이충분한지식을배우고이를실천하도록독려하는데있어서의료공급자의역할은매우중요하기때문이다. 15) 상용치료원이만성질환의관리에긍정적인영향을미친다는것은이미여러연구들을통해알려져있다. 16-19) Moy (1995) 의연구에따르면, 상용치료원이없는고혈압환자는소득과관계없이상용치료원이있는환자에비해집단검진, 추적조사, 약물치료를덜받았으며, 19) He (2002) 는성별및인종, 보험여부와더불어상용치료시설또는의사가있는고혈압환자가혈압관리가잘되며, 혈압체크와생활습관교정도더많이한다고보고하였다. 18) DeVoe 등 (2009) 은당뇨환자를대상으로당뇨관련치료를받는비율을따져보았을때, 상용치료원여부가보험여부와유사하게작용한다고보고하였다. 17) 우리나라일부연구들도상용치료원을통한높은치료지속성이예방서비스이용및질병관리의효과를증가시키고, 불필요한의료이용을줄여의료비를감소시킨다고보고하였다. 20-22) 당뇨병환자의건강보험자료를이용하여추적관찰한김재용등 (2006) 의연구에따르면, 단일기관을주기적으로방문하는환자일수록입원, 사망, 고비용이발생할확률이더낮았다. 20) 또한홍두호등 (2008) 의연구에따르면, 만성질환등록관리체계에등록되어동일한의료기관으로부터지속적인의료서비스를이용하는환자군이그렇지않은군보다치료순응도와혈압및혈당의조절정도가더좋았다. 22) 김진현과조홍준의연구에서도상용치료원의보유는건강검진과같은예방적서비스이용과질병의효율적관리에기여하는것으로나타났다. 21) 적절한의약품복용이만성질환의관리와치료에서중요한역할을차지하고있음을고려할때, 상용치료원의이러한긍정적효과는의약품복용에서도나타날수있을것이라예상된다. 상용치료기관을이용하면서형성된의료기관및의사와의신뢰관계, 그리고환자의복약상황에대한의료진의꾸준한모니터링은환자의복약순응도를높이는데기여할수있기때문이다. 그러나아직까지우리나라에서상용치료원이환자들의복약순응도에어떠한영향을미치는지는연구된바가없다. 이에본연구에서는상용치료원의이용이복약순응도에긍정적인영향을미칠것이라는가설하에, 한국의료패널자
130 / Korean J Clin Pharm, Vol. 26, No. 2, 2016 료를이용해상용치료원의확보가만성질환환자들의투약지속및복약준수이라는복약순응의두형태모두와어떠한관련성을갖는지살펴보고자하였다. 연구방법 연구자료본연구에서는한국보건사회연구원과국민건강보험공단에의해구축된한국의료패널자료중 2012년자료를분석에사용하였다. 한국의료패널은보건의료서비스관련정책의기초정보를제공하기위한목적으로구축되었으며대상자들의질환, 의료이용, 의료비지출, 건강관련인식및행태등에대한정보를포함하고있다. 한국의료패널의표본은 2005년인구주택총조사 90% 전수자료를토대로전국 16개광역시도와동 읍 면을층화변수로한확률비례 2단계층화집락추출방법에의해추출되었다. 25) 2012년데이터의대상가구는총 5,434가구이며가구원은총 15,872명으로, 본연구에서는만성질환으로진단받아의료기관을이용중인 20세이상성인 4,617명을연구대상으로선정하였다. 그중연구의주요변수에대해응답하지않은 199명은분석대상에서제외하고최종적으로 4,418명을분석하였다. 본연구는서울대학교생명윤리위원회로부터 IRB승인을받았다 (IRB No. E1507/001-004). 주요변수 종속변수 본연구의종속변수는 복약불순응 으로, 지난 1년동안만성질환을관리및치료하기위해처방약을복용하지않은경우 ( 의사가처방하지않아서복용하지않은경우는제외 ), 의약품을복용중이나정해진복용방법대로복용하지않는경우를모두복약불순응으로정의하였다. 복약순응도는환자의질환별로조사가되어있으므로, 이를개인별자료로만들어분석하기위해 2개이상의만성질환을앓고있는환자의경우에는단한개의질환에대해서라도복약불순응이있었으면그환자는복약불순응한것으로변수값을부여하였다. a 용치료원으로서의의료기관과의사가있는지를각각질문하였다. 그밖의통제변수로는의료이용이나복약순응도에영향을미치는것으로알려진개인의인구학적및사회경제적요인으로성별, 연령, 교육수준, 결혼상태, 소득, 의료보장형태종류를포함하였고, 개인의건강상태를보정하기위해만성질환개수와 CCI (Charlson comorbidity index) 를포함하였다. CCI는 17 개의질환군에대하여중증도에따라 1-6점의가중치를부여하여이를합한것으로, 중증도가다른여러만성질환이모두같은의료서비스필요도를가지는것으로가정하는방법론상의한계를극복하고질병의중증도를보정하기위해많이사용된다. 26) 본연구에서는한국의료패널 2012년자료의만성질환설문에서조사된진단코드 (KCD-6) 중 17개질환군에해당하는진단코드에가중치점수를부여하여 CCI를계산하였다. 연령은 10세구간별로, 교육수준은분석대상자들의평균연령이높은것을고려하여무학, 초졸, 중졸, 고졸, 대졸이상으로구분하였다. 소득은가구원수를보정한가구소득인가구균등화소득을이용하여연소득천만원미만, 천만원 ~2천만원, 2천만원 ~3천만원, 3천만원이상으로구분하였다. 의료보장형태는건강보험가입자와의료급여및특례자로구분하였다. 만성질환개수는 1개, 2-3개, 4개이상으로구분하였으며, CCI는 0, 1, 2, 3+ 으로구분하여분석하였다. 분석방법우선, 응답자들의일반적특성에따라복약순응의비율이어떻게다른지살펴보기위해카이제곱검정을통한단변량분석을실시하였다. 이후, 복약불순응에관련된요인을파악하고상용치료원여부가이에미치는영향을살펴보기위해다변량로지스틱회귀분석 (Multivariate Logistic Regression) 을실시하였다. 이때상용치료원여부를주요방문기관과주요방문의사의여부로나누어각각의모델을구성하였다. 또한종속변수인복약불순응에대해서도복약미지속과복약방법미준수로각각구분하여상용치료원의효과가이에차등적으로나타나는지추가적으로살펴보았다. 로지스틱회귀분석을통한결과는오즈비와 95% 신뢰구간으로제시하였으며, 분석에는 STATA 10.0 (StataCorp LP, TX, USA) 을사용하였다. 독립변수본연구에서는상용치료원이있는지여부를핵심독립변수로고려하였다. 상용치료원은두가지로구분되어조사되었는데, 아플때나검사또는치료상담을위해주로방문하는의료기관이있는지와주로방문하는의사선생님이있는지, 즉상 연구결과 응답자들의일반적특성만성질환을가진전체분석대상자 4,418명의주요진단코드를분석한결과, 다빈도 10개질환으로는당뇨, 고지혈증, 비염, a 설문의구체적인질문의형태는다음과같다. 1) 님께서는지난 1 년동안 질환을관리및치료하기위해처방약 ( 연고, 주사제포함 ) 을복용하셨거나하고계십니까? ( 예, 아니오응답 ) 2) 질환을관리및치료하기위해정해진복용방법대로복용하십니까? ( 정해진방법대로복용하는편이다, 정해진방법대로복용하지않는편이다 ).
만성질환자의상용치료원이용과복약순응도간의관계 / 131 출혈성위염, 관절증, 고혈압, 백내장, 등통증, 골다공증, 추간판장애가포함되었다. 분석대상자중치료및상담을위해주로방문하는의료기관 ( 상용치료의료기관 ) 이있다고응답한사람은전체의 42.7% 였으며, 그중주로방문하는의사까지있다고응답한사람은 29.5% 였다. 전체대상자중상용치료원보유비율은남녀모두 42% 정도로비슷하였다. 대상자들의평균연령은 60.6세로, 50대이상의응답자가전체의 3/4 이상을차지하였으며, 연령대가높아질수록상용치료원을보유하고있다고응답한비율도순차적으로높아졌다. 건강보험유형에따른상용치료원이용비율은의료급여수급자및특례대상자들이 53% 로건강보험가입자 41% 보다더높았다. 분석대상자들의가구균등화소득은연평균 2,017만원으로나타났으며, 가구소득이높아질수록상용치료원이용비율은더낮았다. 교육수준에서는무학과중졸이하의학력을가진사람들이전체의절반이상을차지하였는데, 교육수준이높아질수록상용치료원이용비율은순차적으로낮아졌다. 미혼자들의상용치료원이용비율은 28% 로기혼 42%, 이혼 / 별거 / 사별 46% 와크게차이를보였다. 대상자의 70% 가량이 2개이상의만성질환을앓고있었으며, 대체로앓고있는만성질환수가많을수록, 그리고동반상병지수 (CCI) 가높을수록상용치료원보유비율도높았다. 또한응답자의약 30% 가처방의약품을복용하지않거나용법, 용량대로복용하지않은것으로나타났는데, 복약불순응인사람들이복약순응인사람들보다상용치료원이용비율이더낮았다 (Table1). Table 1. Prevalence of having usual source of care according to respondent s basic characteristics (KHP 2012) (N = 4,418). Characteristics Total N People % of having a usual source of care Sex Male 1901 42.35 0.689 Female 2517 42.95 Age group (years) 20-29 113 14.16 < 0.001 30-39 253 28.85 40-49 622 32.48 50-59 901 38.62 60-69 1137 47.05 70+ 1392 51.15 Health insurance type National health insurance 4062 41.78 < 0.001 Medical assistance program 356 53.09 Annual household income < 10 million won 1163 51.50 < 0.001 10~20 million won 1492 40.75 20~30 million won 954 38.47 > 30 million won 809 38.57 Education No formal education 358 47.49 < 0.001 Under elementary school 1282 47.11 Under middle school 736 41.17 Under high school 1211 42.20 College or more 831 35.86 Marital status Married 3338 42.72 < 0.001 Divorced/separated/widowed 854 46.37 Single 226 28.32 No. of chronic dx 1 1262 30.43 < 0.001 2-3 1633 44.34 More than 4 1523 51.08 CCI 0 2860 37.03 < 0.001 1 1053 51.47 2 350 55.14 3 + 155 59.35 Adherence to medication Yes 3081 46.09 < 0.001 No 1337 34.85 a Chi-square test P a
132 / Korean J Clin Pharm, Vol. 26, No. 2, 2016 Table 2. Reasons for non-adherence to medication. a Reasons for not taking prescribed medicines(n=915) Reasons for not following the direction of medication(n = 3,414) type % type % Consider themselves at lower risk 36.4 Felt better 47.9 Not effective 5.5 Not effective 5.9 Concerns about side-effects 2.7 Experience of side-effects 2.5 Financial burden on out-of-pocket payment for prescription drugs 1.0 Forgot to take medicines 36.2 Ongoing non-medicine treatment 53.1 Concerns about long term medication 6.4 Others 1.3 Others 1.0 a Reasons for non-adherence to medication were asked to respondents by each chronic disease that they have, so total N is more than the number of respondents. 처방받은의약품을조제하지않거나복용하지않는이유로는약이외의치료중이거나약을먹을만큼심각하지않아서라는대답이가장많았고, 효과가없거나부작용에대한우려, 경제적인이유때문이라는응답도있었다. 한편, 정해진복용법대로처방약을복용하지않은사람들의대부분은증상이완화되거나약먹는것을잊어버린경우였으며, 효과가없거나부작용경험및우려때문인경우도있었다 (Table 2). 회귀분석결과 Table 3에는상용치료원의확보가만성질환자들의복약순응도에어떤영향을미치는지확인하기위해실시한로지스틱회귀분석결과를제시하였다. 상용치료원이있는환자들은복약불순응을보고할가능성이낮았으며, 이는다른사회경제적변수나건강상태를보정한이후에도통계적으로유의하였다. 또한이는주요방문의료기관이있는경우 (Model 1) 나의사가있는경우 (Model 2) 모두에서관찰되었다. 성별과만성질환수, CCI 역시복약순응도에유의한영향을미쳤는데, 여성이남성보다, 그리고만성질환을 4개이상앓고있는사람들이 1개만을앓고있는사람보다복약불순응도가높았으며, 앓고있는만성질환수가많을수록순차적으로복약불순응가능성도커지는것을확인할수있었다. CCI가 0인경우에비해 1이나 2인경우복약불순응도가낮았지만, 3인경우에는유의한차이가발견되지않았다. 그외연령이나건강보험상태, 소득수준, 결혼상태는복약불순응에유의한영향을미치지않는것으로나타났으며, 교육수준에서는대학재학이상의학력수준을가진사람들에비해고졸미만인사람들의복약불순응도가다소낮았다 (Table 3). 한편복약불순응의형태 ( 의약품미복용 vs. 복용법미준수 ) 에따라각변수들의영향이달라지는지확인하기위해각각에대해회귀분석한결과를 Table 4에제시하였다. 분석결과, 상용치료원의유무는의약품미복용과복용법미준수모두에유의하게영향을미쳐, 상용치료원이존재할경우각각의오즈비는유의하게낮게나타났다. 그러나그밖의다른독립변 수들의영향은양쪽에서서로조금씩다르게나타났는데, 우선여성의경우남성에비해처방약을복용하지않을가능성이유의하게높게나타난데반해, 복용법을제대로지키지않는것에서는성별의차이가나타나지않았다. 한편의약품미복용에서는연령에따른통계적인차이가발견되지는않았으나복용법준수와관련하여서는 40대가 20대에비해약두배가량복용법을지키지않는것으로나타났으며이는통계적으로유의하였다. 또한교육수준이높아질수록의약품을미복용할가능성도순차적으로높아졌지만, 복용법준수에있어서는학력에따른유의한차이가관찰되지않았다. 만성질환수가증가할수록의약품미복용과복용법미준수의가능성은순차적으로높아졌는데, 특히의약품미복용에더큰영향을미쳐만성질환을 4개이상앓고있는경우의약품미복용의오즈비는 2.47, 복용법미준수의오즈비는 1.41로나타났다. 마지막으로 CCI의값이 1인사람들은 0인사람들에비해의약품미복용과복용법미준수의확률이낮았지만그이상의값을갖는경우에는유의한차이가없었다 (Table 4). 고찰 본연구에서는의료패널자료를이용하여상용치료원의이용과만성질환환자들의복약순응도간의관련성에대해살펴보고자하였다. 분석결과, 만성질환자의약 30% 는복약을중단하거나복약지시대로사용하지않은 복약불순응 을경험하였으며, 상용치료원은이러한만성질환자의복약순응도와밀접하게관련되어있었다. 또한상용치료원의존재는그것의형태가기관이든의사이든관계없이만성질환자에서높은복약순응과관련성을보였다. 이러한상용치료원과만성질환약물사용간의관계에대한연구는주로미국에서많이이루어져왔다. 이는보편적건강보험이없는미국보건의료체계에서, 지속적인약물접근을유지시키는데있어상용치료원의가능성에대한관심에서비롯되었다고볼수있다. 미국을비롯하여주요선진국들인호주,
만성질환자의상용치료원이용과복약순응도간의관계 / 133 Table 3. The logistic regression model on non-adherence to medication. a Model 1 Model 2 Variables OR b (95% CI) c OR (95% CI) Having a regular site as a usual source of care No Yes 0.61 *** (0.53-0.70) Having a regular doctor as a usual source of care No Yes 0.67 *** (0.58-0.78) Sex Male Female 1.23 *** (1.06-1.42) 1.23 *** (1.06 1.43) Age group(years) 20-29 30-39 1.56 (0.88-2.76) 1.50 (0.85-2.65) 40-49 1.63 * (0.92-2.90) 1.56 (0.88-2.67) 50-59 1.27 (0.70-2.30) 1.20 (0.66-2.16) 60-69r 1.20 (0.66-2.20) 1.11 (0.61-2.03) 70+ 1.35 (0.73-2.49) 1.24 (0.67-2.29) Type of health insurance NHI d MAP e 1.09 (0.84-1.40) 1.08 (0.84-1.38) Annual household income < 10 million won 1.08 (0.86-1.37) 1.07 (0.85-1.35) 10~20 mil. Won 0.97 (0.79-1.18) 0.98 (0.80-1.19) 20~30 mil. Won 0.95 (0.77-1.17) 0.95 (0.77-1.17) >30 mil. won Education No formal education 0.88 (0.63-1.23) 0.89 (0.63-1.24) Under elementary 1.01 (0.79-1.29) 1.02 (0.79-1.30) Under middle school 0.95 (0.74-1.23) 0.97 (0.76-1.25) Under high school 0.83 * (0.68 1.03) 0.84 * (0.68-1.03) College or more Marital status Married Others f 1.03 (0.86-1.25) 1.04 (0.86-1.25) Single 1.12 (0.75-1.68) 1.09 (0.72-1.63) No. of chronic disease 1 2-3 1.05 (0.88-1.25) 1.03 (0.87-1.23) More than 4 1.61 *** (1.32-1.97) 1.57 *** (1.28-1.91) CCI 0 1 0.67 *** (0.57-0.80) 0.67 *** (0.57-0.80) 2 0.76 ** (0.59-0.98) 0.74 ** (0.57-0.96) 3+ 0.86 (0.60-1.25) 0.83 (0.58-1.20) *p < 0.1, **p < 0.05, ***p < 0.01 Italic indicates a reference group. a Two different definitions of a usual source of care are applied in model 1 and 2: having a regular site in model 1; having a regular doctor in model 2. b Odds Ratio, c Confidence Interval, d NHI: National Health Insurance, e MAP: Medical Assistance Program, f Divorced, separated, or widowed
134 / Korean J Clin Pharm, Vol. 26, No. 2, 2016 Table 4. The logistic regression model on medication non-persistence and non-compliance. Non-persistence Non-compliance OR a (95% CI) b OR (95% CI) Having a usual source of care No Yes 0.66 *** (0.54-0.81) 0.65 *** (0.56-0.76) Sex Male Female 1.51 *** (1.21-1.87) 1.12 (0.95-1.32) Age group (years) 20-29 30-39 1.13 (0.48-2.70) 1.71 (0.90-3.28) 40-49 1.00 (0.41-2.40) 2.01 ** (1.05-3.86) 50-59 0.90 (0.36-2.21) 1.59 (0.81-3.11) 60-69r 1.02 (0.41-2.55) 1.34 (0.68-2.67) 70+ 1.00 (0.39-2.54) 1.58 (0.79-3.18) Type of health insurance NH c MAP d 0.85 (0.58-1.24) 1.18 (0.90-1.55) Annual household income < 10 million won 0.99 (0.71-1.38) 1.16 (0.89-1.50) 10~20 mil. Won 0.79 (0.59-1.06) 1.08 (0.86-1.36) 20~30 mil. Won 0.91 (0.67-1.23) 0.96 (0.76-1.23) > 30 mil. won Education No formal education 0.52 ** (0.32-0.86) 1.12 (0.77-1.63) Under elementary 0.70 ** (0.49-0.99) 1.20 (0.91-1.58) Under middle school 0.75 (0.52-1.08) 1.09 (0.82-1.45) Under high school 0.79 (0.58-1.07) 0.91 (0.71-1.15) College or more Marital status Married Others e 0.99 (0.76-1.29) 1.07 (0.88-1.32) Single 0.79 (0.40-1.53) 1.35 (0.87-2.09) No. of chronic disease 1 2-3 1.22 (0.93-1.61) 1.07 (0.88-1.31) More than 4 2.46 *** (1.83-3.31) 1.41 *** (1.13-1.77) CCI 0 1 0.60 *** (0.46-0.78) 0.76 *** (0.63-0.92) 2 0.80 (0.56-1.14) 0.81 (0.61-1.08) 3+ 1.02 (0.63-1.66) 0.72 (0.47-1.12) *p < 0.1, **p < 0.05, ***p < 0.01 Italic indicates a reference group. a Odds Ratio, b Confidence Interval, c NHI: National Health Insurance, d MAP: Medical Assistance Program, e Divorced, separated, or widowed 캐나다, 독일, 네덜란드, 뉴질랜드, 영국등에서상용치료원을보유한환자비율은 90% 이상에이르며, 주치의로만한정하여도미국민의약 80% 가주치의를보유하고있는것으로알 려져있다. 27) 이렇듯미국에서는상용치료원의보유비중이높은편이기때문에이를통해보편적건강보험의부재로인한만성질환관리의한계를상용치료원으로보완할수있는지가
만성질환자의상용치료원이용과복약순응도간의관계 / 135 연구되었다. 반면에우리나라의경우는보편적건강보험제도를운영하고있지만상용치료원을보유한환자의비율은매우낮은편이다. 2012년의료패널자료분석에따르면만성질환자중상용치료원을가지고있는경우는 42%, 주치의가있는경우는약 30% 에그쳤다. 보편적건강보험은의약품이용에대한재정적부담을낮춤으로써경제적장벽으로인한복약불순응의발생을상당부문상쇄시킬수있으리라기대되지만, 23) 그럼에도불구하고본연구결과에서드러난상용치료원과복약순응도간의높은연관성은복약순응도제고를위해의료전달체계문제에도관심을기울여야할필요성을시사한다. 복약불순응은경제적인요인외에도다양한요인에의해영향을받는데, 실제로의료패널자료를이용하여의약품미복용의이유를파악한결과, 해당질환에대한약물치료효과에확신을갖지못해서인경우가많았고, 경제적인이유는상대적으로높지않았다. 또한복용법미준수의원인중가장많은비율을차지한것은증상이완화되거나약먹는것을잊어버린경우와효과가없거나부작용경험및우려때문이었다. 이는복약불순응의두가지차원모두에서치료방법에대한환자의신뢰제고, 약물복용준수습관에대한고무와지지, 부작용과같은문제가발생했을때이에대한대처, 그리고이를지속적으로모니터링할수있는의료전달체계의필요성을시사하며, 상용치료원이이러한자원으로기능할수있다는가능성을보여준다. 또한이러한결과는복약순응도연구에서그동안상대적으로간과해왔던공급자요인혹은제도적요인이갖는중요성을환기시킨다고볼수있다. 만성질환관리에상용치료원이미치는이러한긍정적효과는주로의사-환자관계의지속성측면에서해석되어왔다. 의사-환자관계지속을통해상호간지식이축적되고, 조정 (coordination) 효과가증대됨으로써질환관리에기여한다는것이다. 또한그러한차원에서본다면다양한의료공급자가근무하고있는의료기관의다른의사일지라도정보공유가가능할경우역시상용치료원으로서작용할수있다는견해도있다. 28) 본연구결과에서상용치료원이동일의사여부에관계없이모두복약순응도에유의한영향을미친것은이러한맥락으로해석할수있을것이다. 본연구는복약불순응을두차원으로나누어그영향요인을각각검토하였다. 그결과, 상용치료원의독립적영향은두차원에서일관되게나타나지만, 다른변수들의영향에서다소차이를발견할수있었다. 우선복약불순응을하나의차원으로분석했을때나타났던성별차이가의약품미복용및복용법미준수라는차원으로나누어분석하면, 복용법미준수에서는나타나지않았다. 교육수준역시의약품미복용가능성과는 연관되었지만, 복용법미준수와는연관되지않았고, 만성질환수에따른영향도복용법미준수보다의약품미복용에서더컸다. 종합하면약물불순응을의약품미복용과복용법미준수차원으로구분하였을때, 성별, 교육수준, 만성질환수가약물미복용, 즉지속성의차원에더영향을미치는것으로나타났다. 따라서복용법미준수보다의약품미복용에서환자의사회경제적차이가더크게드러날수있음을보여주고있다. 또한그간연구에서이부분을미충족의료로다루어왔던점 3) 에주목할때, 상용치료원이미충족의료에도영향을미칠수있다는점도동시에보여준다고할수있다. 본연구를통해만성질환자들의상용치료원이용이환자들의복약순응과상관성이높다는것을확인할수있었지만, 다음과같은몇가지한계점이존재하였다. 우선, 2012년 1개년도자료만을분석한단면연구로서두변수간의인과성추정에한계가있다는점이다. 즉, 상용치료원이용이복약순응도를높이는방향으로영향을미칠수도있지만, 반대로복약순응을잘하는사람들이그렇지않은사람들보다상용치료원을더많이이용할성향의가능성도배제할수없다. 한국의료패널에서는상용치료원에대한질문을 2009년과 2012년두번에걸쳐한바있는데, 질문방식이서로달라본연구에서는 2012년자료만을활용하였다. b 추후조사가더이루어진다면, 패널자료를이용한분석을통해이러한역인과성문제를극복할수있으리라생각한다. 또다른한계는복약순응도에영향을미치는일차의료의질적인측면은반영하지못했다는점이다. 본연구에서활용한 상용치료원유무 는일차의료의여러가지속성중최초접촉과지속성을추정할단서에불과할뿐, 과연구체적으로일차의료의어떤속성이환자의복약순응도에기여하는지그메커니즘에대해서는자세히알수가없다. 결론 상용치료원의이용은동일의사여부에관계없이만성질환자의높은복약순응과유의한관련성을보였다. 또한복약행태를지속적복용여부와복용방법준수여부로나누어보았을때도, 상용치료원의이용은이각각과모두유의한관련성을보였다. 이러한결과는복약순응도제고, 나아가만성질환의효과적관리에상용치료원이긍정적역할을수행할수있다는가능성을확인한다. 2012년 4월부터만성질환자들에게상용치료원을갖도록하여치료지속성및복약순응도를높이고자의원급만성질환관리제가시행되어고혈압및당뇨병환자가일차의료기관에서적절한진료를받도록지원하고있다. 그리고최근의평가에서이러한만성질환관리제참여환자들의동일외래기관지속방문및투약순응도가높아졌다는보고가있 b 2009 년에는상용치료원에대해주로방문하는의료기관이있는지여부로만질문한데반해, 2012 년에는주로방문하는의료기관과함께주로방문하는의사가 있는지를추가로질문함.
136 / Korean J Clin Pharm, Vol. 26, No. 2, 2016 었다. 29) 그러나한편으로는공급자들이만성질환관리제참여에적극적이지않은측면을고려해볼때, 상용치료원의정착에는제도적차원을넘어서더광범위한맥락의문제들이함께고려될필요가있을것으로보인다. 복약순응도는임상약학의가장중요한관심사중하나이다. 그런데, 그간임상에서복약순응에대한관심은처방이행의차원에집중되고, 복약지속이라는측면에는상대적으로관심이적었다. 그런데, 만성질환의관리에서두가지차원모두가상용치료원과양의상관성을가진다는본연구결과는임상약학적지식의실현에제도와맥락이밀접하게관련된다는것을인식하게한다. 즉, 임상약학적근거가정책수립에근거가되어야할뿐만아니라, 사회정책이임상결과에영향을미칠수있다는상호적관계에대해관심을기울일필요가있다. 감사의말씀 본연구는 2014년도미래창조과학부의재원으로한국연구재단의지원을받아수행되었습니다 (No. NRF-2014R1A1A- 3052952). 참고문헌 1. WHO. World Health Statistics. Geneva; Switzerland: World Health Organization; 2010. 2. Korea National Health Insurance Service, Health Insurance Service and Assessment Service. National health insurance statistictial year book 2011. 2011. 3. Huh SI, Lee SH. Unmet health care needs and associated factors among patients with hypertension and those with diabetes in Korea. Health Policy Manag 2011;21(1):1-22. 4. Cramer JA, Roy A, Burrell A, et al. Medication compliance and persistence: terminology and definitions. Value in Health. 2008;11(1):44-7. 5. Park EJ. Medication compliance: factors and interventions. Health- Welf Policy Forum 2011:82-91. 6. Park C, Chang S, Chang S, et al. The analysis on medical expenditure and health outcomes by continuity of care- experiene of hypertension and diabetes: Health Insurance Review and Assessment Service; 2010. 7. Jang SM, Song HJ, Shin SY, et al. Development of evalation indicators for Antihypertensive drugs: Health Insurance Review and Assessment Service; 2008. 8. Park JH. Antihypertensive drug medication adherence of national health insurance beneficiaries and its affecting factors in Korea. J Prev Med Public Health 2007;40:249-58. 9. Hong J-S, Kang H-C. Oral antihyperglycemic medication adherence and its associated factors among ambulatory care with adult type 2 diabetes patients in Korea. Health Policy Manag 2010;20(2):128-43. 10. Huh SI, Lee H. Unmet Health Care Needs and Attitudes towards Health Care System in Korea. Korean J Health Econ Policy 2016; 22(1):59-89. 11. Kim S. Medication Adherence of Elderly with Hypertension and/or Diabetes-mellitus and its' Influencing Factors. Korean J Clin Pharm 2011;21(2):81-9. 12. Lee EK, Choi YO. Analysis of Medication Compliance and Polypharmacy for the Old Diabetic Patients. J Korean Soc Health Educ Promot 2000;17(1):81-93. 13. Lee EK, Park JY. Analysis of Factors Affecting Medication Compliance of Outpatients. Korean J Quality Health Care 2002;9(2):164-75. 14. Chang E, Chan KS, Han H-R. Factors associated with having a usual source of care in an ethnically diverse sample of Asian American adults. Med Care 2014;52(9):833-41. 15. Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. Jama 2002;288(19):2469-75. 16. Centers for Disease Control Prevention. Vital signs: prevalence, treatment, and control of hypertension--united States, 1999-2002 and 2005-2008. MMWR. Morbidity and mortality weekly report 2011; 60(4):103. 17. DeVoe JE, Tillotson CJ, Wallace LS. Usual source of care as a health insurance substitute for US adults with diabetes? Diabetes Care 2009;32(6):983-9. 18. He J, Muntner P, Chen J, et al. Factors associated with hypertension control in the general population of the United States. Arch Intern Med 2002;162(9):1051-8. 19. Moy E, Bartman BA, Weir MR. Access to hypertensive care: effects of income, insurance, and source of care. Arch Intern Med 1995;155(14): 1497-1502. 20. Kim J, Kim H, Kim H, et al. Current Status of the Continuity of Ambulatory Diabetes Care and its Impact on Health Outcomes and Medical Cost in Korea Using National Health Insurance Database. Diabetes 2006;30(5):377-87. 21. Kim JH, Cho HJ. The effect of having regular source of care on providing preventive service and disease management. Korean J Fam Med 2007;28(04):278-85. 22. Hong D, Seo H-j, Kang K-h, et al. Impact of Registration Program after Hypertensive or Diabetic Patient Detection through Community Partnership on Compliance and Blood Pressure or Blood Sugar Control. J Agric Med Community Health 2008;33(3):316-23. 23. Spatz ES, Ross JS, Desai MM, et al. Beyond insurance coverage: Usual source of care in the treatment of hypertension and hypercholesterolemia. Data from the 2003-2006 National Health and Nutrition Examination Survey. Am Heart J 2010;160(1):115-21. 24. Kerse N, Buetow S, Mainous AG, et al. Physician-patient relationship and medication compliance: a primary care investigation. Ann Fam Med 2004;2(5):455-61. 25. Seo NG, Ahn S, Hwang YH, et al. Basie analysis report on Korea Health Panel 2012 National Health Insurance Service, Korea Instit Health and Soc Welf; 2014. 26. Lim JH. Analysis of unmet medical need status based on the Korean Health Panel. J Health Soc Sci 2013;34:237-56. 27. Schoen C, Osborn R, Doty MM, et al. Toward higher-performance health systems: adults health care experiences in seven countries, 2007. Health Aff 2007;26(6):w717-w734. 28. Mainous III AG, Koopman RJ, Gill JM, et al. Relationship between continuity of care and diabetes control: evidence from the Third National Health and Nutrition Examination Survey. Am J Public Health 2004;94(1):66-70. 29. Baek J, Lee S, Kwak D, et al. An analysis on health care utilization among users of Chronic Diseases Management Program in primary care: National Health Insurnace Service; 2015.