High risk factor를 同伴한 新生兒에 關한 硏究

최규종 漢陽大學校 大學院 1978 국내석사

Public Health Concerns, Risk Perception and Information Sources in Cameroon

TINYAMI ERICK TANDI 고려대학교 대학원 2016 국내박사

Abstract Objectives: Sampling public perception regarding health risks may cut across different factors ranging from; if the risk in question evokes feelings of dread, if the issue is well understood, whether it involve uncertainty, if it is a subject of personal control, or familiarity and media courage. Considering that, public perception on health risks could aid in shaping the way experts assess and direct decisions regarding health risk factors, it is of importance to closely examine their views. This study was designed to investigate the degree of public perception associated with various health risk factors, their information sources and the confidence on the sources of information to Cameroonians nationwide. The results are aimed towards contributing to a better understanding of perceived health risk factors and health status profile of Cameroonians, which could allow for the development or re-enforcement of health prevention/promotion programs of the nation. Methods: This was a national population-based cross-sectional survey that was conducted using a self-administered questionnaire designed to sample public perceptions on different health risk factors amongst Cameroonians. Based on the 2010 national population census, proportional quota sampling were used to ensure that respondents were demographically representative of the general population, with quotas based on gender and regions. Cameroonians adults of both sexes with age ≥ 20 years took part in the survey. A total of 1,067 Cameroonians were sampled within the 10 regions of the nation taking into account the proportional quotas based on gender. Descriptive statistical analyses were performed to illustrate the levels of risk perceived according to differences in mean score values as “high health risk” with respect to gender, age, education, income and region of location. Factors analysis was used to reduce the dimensions of common attributes of the risk factors into simpler dimensions using principal component and Varimax rotation methods. Independent two sample t-test was performed to examine the group differences in perceived risk for each hazard based on gender. ANOVA analysis was also performed to analyse the differences in risk perception through a comparison of the different issues with age, education, income and geographic differences. Statistical significance tests was at p˂0.05. Results: Public health concerns of twenty-five selected health risk factors to Cameroonians were analyzed and ranked according to mean score values perceived to be a “high health risk”. HIV/AIDS was perceived as posing the greatest personal health risk with a mean score of 6.58 ± 1.12 within the population. By combining the psychometric variables to determine the overall mean scores, terrorism was perceived as the greatest health risk factor with mean score value of 5.82 ± 0.51 to the nation. Natural disasters, unprotected sex, unemployment, drinking alcohol, cigarette smoking, poverty, malaria, and cholera were also among the leading perceived health risk factors to the population. Women perceived selected health risk factors more than men. The greatest perceived gender mean score difference of 0.51 was observed for unemployment. There was a great significant differences between perceived health risk factors based on regional location. All perceived risk factors were statistically significant across the different regions at (p˂0.05). Also, poverty, high voltage power lines and influenza had high mean score differences for age groups, educational and income levels respectively. Statistically significant differences were observed for poverty and measles based on income at (p˂0.05). Using factor analysis to reduce the dimensions of common attributes among the risk factors to simpler ones based on gender, knowledge and dread factors for perceived health risks were ranked differently. For the analyses based on knowledge, women and men ranked natural disaster (flood, landslide, eruption etc), and terrorism as the highest risk factors respectively. With regards to dread, terrorism was ranked the highest for both women and men. Conclusion: The present large scale survey of public opinions among Cameroonians provided some valuable information on their perception regarding selected health risk factors, information sources and the level of confidence on the information sources in Cameroon. Generally, the risk factors presented in this study were scored as posing a potential “high health risk” to the population. Experts and managers interested in population health may want to consider taking some measures that will address these issues, in order to effectively communicate and control the consequences that may emanate from their accidents. Although this study sampled public views limited to Cameroon, it could stand as a guide on public perception regarding health risk factors in a developing setting such as those of Sub-Saharan Africa where there is a dearth of information in this area of research. HIV/AIDS and terrorism that were perceived to be beyond individual control as the highest perceived health risk factors among others in Cameroon, the government may want to consider public views and take inclusive measures that will properly identify and address the issues that may result to further complications arising from their effects within the nation. Also, the results obtained from this study should be carefully interpreted, and policies directed towards the effective communication of health risk management strategies within the communities aimed at the development of health prevention/promotion programs of the nation should be encouraged.

Analysis of early failure rate and risk factors of national insurance covered dental implants : a nationwide study using National Health Insurance database in South Korea

유진주 Graduate School, Yonsei University 2020 국내박사

The aims of this study are to analyze the early failure rate of the National Health Insurance covered (NHIC) dental implants and the factors that have influenced on the early implant failure, using National Health Insurance Service (NHIS)-Customized database. The null hypothesis is that the early implant failure occurs equally regardless of the patient's socio-demographic, systemic and intraoral factors, institutional factors and implant factors. The NHIC dental implants consist of three stages: stage 1 diagnosis and treatment planning, stage 2 fixture placement operation, and stage 3 prosthetic restoration. Although the second stage had been completed by placing the implant fixture, if failure of osseointegraion occurred before the third stage, the new fixture could be placed after removing the existing fixture. In this study, the early failure of NHIC dental implants was defined as the fixture placement re-operation. We selected individuals who treated with NHIC dental implants from July 2014 to December 2017 and analyzed the risk factors affecting the early failure of implants using the Cox proportional risk model. The findings are as followings, 1. 1,242,101 implants were placed in a total of 740,241 patients between July 1, 2014 and December 31, 2017, since the NHIC dental implant introduced. Among these, 4,279 implants were replaced due to the failure of osseointegration and the early failure rate was 0.34%. 2. For the patients’ socio-demographic factors, the risk of early implant failure was high in men and residents of Seoul. Early implant failures did not differ by age, income level, social security type and insurance eligibility. 3. Depending on the systemic factors of the patient, the risk of early implant failure was high for diabetic patients with medication and current smokers. On the other hand, whether hyperlipidemia, osteoporosis and diabetes were diagnosed, alcohol consumption and body mass index (BMI) did not affect early implant failure. 4. According to the patients’ intraoral factors, the more invasive periodontal treatment individual had, the higher the risk of implant failure. Mandibular anterior area showed the highest risk of the early implant failure. 5. For the institutional factors, the failure risk of the NHIC dental implants in dental clinics was higher than that in general hospitals and tertiary general hospitals. Medical institutions that placed the top 50 % of implants based on the number of implants showed a lower risk of early implant failure compared to those placed the lowest number of implants. 6. According to the implant factors, submerged type implants that internally connected had a higher risk of early implant failure externally connected implants and implants with RBM surface had a higher risk of early implant failure than those with SLA surface. Implant Design and the presence of micro-threads did not affect the risk of early implant failure. However, further studies are needed for other factors, such as the manufacturer. It is necessary to carefully consider the risk factors involved in osseointegration failure when planning implant treatment for predictable prognosis. 본 연구의 목적은 국민건강보험공단의 맞춤형연구 데이터베이스를 이용하여 건강보험 임플란트를 시행한 환자들의 임플란트 초기 실패와 이에 영향을 주는 요인을 분석하기 위함이다. 귀무가설은 환자의 인구사회학적 요인(성별, 연령, 소득수준, 건강보험 자격요건, 사회보장 유형과 거주지역), 전신적인 요인(혈압, 당뇨, 고지혈증, 골다공증 등의 전신질환, 신체계측지수, 흡연과 음주), 구강 내 요인(치주질환의 중증도, 임플란트 식립 위치) 그리고 임플란트를 식립한 기관 요인(의료기관 유형 및 시술량) 및 식립된 임플란트 요인(결합방식, 고정체의 표면처리 방식 및 디자인)과 관계없이 임플란트 초기 실패가 동일하게 발생한다는 것이다. 건강보험 치과 임플란트는 1단계 진단 및 치료계획, 2단계 고정체 식립술 그리고 3단계 보철수복의 총 세 단계로 진행된다. 고정체를 식립하여 2단계 시술을 종료하였으나 3단계 보철수복 전에 골유착 실패가 확인되어 고정체를 제거한 후 재식립한 경우를 본 연구에서는 임플란트의 초기 실패라고 정의하였다. 2014년 7월부터 2017년 12월까지 건강보험 치과 임플란트를 시행한 환자의 의료 이용 내역과 건강검진 자료를 활용하였고, Cox 비례위험모형을 이용하여 임플란트 초기 실패에 영향을 미치는 위험요인을 분석하여 다음과 같은 결과를 얻었다. 1. 국민건강보험 맞춤형 자료를 통해 건강보험 임플란트가 시작된 2014년 7월 1일부터 2017년 12월 31일까지 42개월 동안 총 740,241명의 환자에서 1,242,101개의 건강보험 임플란트가 식립되었고, 4,279개의 임플란트가 재식립되어, 초기 실패율은 0.34 %였다. 2. 임플란트 초기 실패의 위험 요인을 분석한 결과, 환자의 인구 사회학적 요인에 따라서 남성 및 서울 거주자의 임플란트 초기 실패 위험이 높았고, 연령, 소득 수준, 사회 보장 유형 및 보험 자격 요건에 따른 차이는 없었다. 3. 환자의 전신적인 요인에 따라서는 당뇨병 약제 복용자, 현재 흡연자의 임플란트 초기 실패 위험이 높았고, 고지혈증, 골다공증 및 당뇨병 진단 여부 그리고 음주 및 체질량지수(BMI)는 임플란트 초기 실패에 영향을 미치지 않았다. 4. 환자의 구강 내 요인에 따라서는 경험한 치주치료의 심도가 높아질수록 실패 위험도 높아졌다. 또한 임플란트의 식립 부위에 따라서는 하악 전치부의 실패 위험이 가장 높았다. 5. 기관 요인에 따라서는, 식립된 임플란트 수를 기준으로 한 상위 50 %의 임플란트 초기 실패 위험이 낮았고, 치과 의원의 임플란트 초기 실패 위험이 상급종합병원과 종합병원에 비해 높았다. 6. 식립된 임플란트 요인에 따라서는 내측 연결형의 매립형 임플란트가 외측 연결형 임플란트보다 임플란트 초기 실패 위험이 높았고, RBM 표면의 임플란트가 SLA 표면의 임플란트에 비해 임플란트 초기 실패 위험이 높았으며, 임플란트 형태 및 미세 나사선의 유무는 임플란트 초기 실패에 영향을 미치지 않았다. 그러나, 제조사 등 다른 요인에 대한 추가적인 분석이 필요할 것이다. 예지성 있는 임플란트 치료를 위하여 치료 계획 수립 시 골유착 실패에 관여하는 요인을 면밀히 고려해야 할 것이다.

소화성 궤양의 위험인자 비교분석

이형근 연세대학교 대학원 2003 국내석사

연구배경 : 소화성 궤양은 흔히 발견되는 질환으로 지속적인 통증 등으로 일상생활에 장애를 초래하며 출혈 또는 천공 등의 치명적인 합병증을 유발하기도 하며 재발이 잦아 임상적으로도 중요하다. 소화성 궤양은 지역, 인종, 성별, 연령 등에 따라서 발생양상이 다르고 직업, 약물복용, 생활습관 및 다른 질환 등과도 관련이 있는 것으로 알려져 있다. 본 연구에서는 소화성 궤양의 과거력이 없으면서 무증상의 건강검진 수검자들을 대상으로 소화성 궤양의 유병율을 조사하였고 위궤양과 십이지장궤양의 발생에 영향을 미치는 여러 인구사회학적 요인과 음주, 흡연, 식이 등의 생활습관을 정상군과 위궤양군, 십이지장궤양군을 각각 비교하였다. 이러한 연구 결과를 통해서 소화성 궤양의 적절한 치료지침을 마련하는데 도움이 되고자 하였다. 방법 : 2002년 7월 1일부터 2002년 10월 15일 사이에 국민건강보험공단 일산병원 건강증진센터 수검자들에게 인구사회학적 특성 및 생활습관에 대하여 설문조사를 실시하였고 혈액검사를 실시하여 혈액형을 확인하였다. 이들은 위장촬영 또는 상부 위장관 내시경검사를 시행 받았고 상부 위장관 내시경검사를 시행 받은 1255명 중 위궤양과 십이지장궤양이 동시에 있는 15명과 조직학적 검사 상 악성궤양으로 판정된 5명, 기타 의무기록이 구비되지 못한 경우 등 184명을 제외한 1071명을 연구대상으로 하였다. 통계학적 검증은 STATA 5.0 statistical software를 사용하였고 연구대상군의 다양한 변수의 분포는 Chi test 또는 ANOVA test를 사용하여 비교되었다. 결과 : 연구대상자 1071명 중 위궤양군은 84명, 십이지장궤양군은 59명이었다. 위궤양군의 남녀 비는 3.4:1로 위궤양의 발생은 성별과 통계적으로 유의하였고 연령은 60세 이상이 85.71%이었으나 연령과 통계적으로 유의하지 않았고 위궤양군에는 전문직과 사무직이 많아 직업의 종류에 따라 통계적으로 유의하였으나 결혼여부, 교육정도, 종교 및 경제수준과는 통계적으로 유의하지 않았다. 위궤양의 발생은 흡연여부 및 흡연량과 유의하였고 음주여부와도 통계적으로 유의하였으나 커피소비여부, 규칙적인 운동여부, 조식여부와는 통계적으로 유의하지 않았다. 위궤양의 발생은 위장관 증상, 혈액형의 종류와는 통계적으로 유의하지 않았으나 위궤양군의 H. pylori 감염율은 74%로 통계적으로 유의하였다. 십이지장궤양군의 남녀 비는 3.5:1로 성별과 통계적으로 유의하였고 연령은 60세 이상이 88.14%이었으나 연령과 통계적으로 유의하지 않았다. 십이지장궤양군에는 주부가 많아 십이지장궤양의 발생은 직업의 종류에 따라 통계적으로 유의하였으나 결혼여부, 교육정도, 종교 및 경제수준과는 통계적으로 유의하지 않았다. 십이지장궤양의 발생은 흡연여부 및 흡연량과 통계적으로 유의하였으나 음주여부와는 통계적으로 유의하지 않았으며 커피소비여부, 규칙적인 운동여부, 조식여부와도 통계적으로 유의하지 않았다. 십이지장궤양의 발생은 위장관 증상, 혈액형의 종류와는 통계적으로 유의하지 않았으나 H. pylori 감염율은 87%로 H. pylori 감염 여부와는 통계적으로 유의하였다. 결론 : 위궤양의 발생은 성별, 직업의 종류, 흡연여부 및 흡연량, 음주여부, H. pylori 감염여부와 통계적으로 유의한 상관관계가 있었으며 십이지장궤양의 발생은 성별, 직업의 종류, 흡연여부 및 흡연량, H. pylori 감염여부와 통계적으로 유의한 상관관계가 있었다. Background : Peptic ulcer is very common and important clinical disease that makes one's life very difficult because it gives rise to continuous epigastric pain and shows high recurrence rate. Peptic ulcer shows different clinical manifestations according to the land, race, sex, age, etc. and is known that it is related to the job, drug administration, life styles and other medical diseases. We surveyed the incidence of peptic ulcer in the health screening receivers who have no past history of peptic ulcer and analysed the dermographic factors, life styles including alcohol drinking, smoking, diet, etc. comparing the non peptic ulcer group, gastric ulcer group, duodenal ulcer group. We hope to be easy in making proper treatment plan in the peptic ulcer disease. Materials and Methods : Between July 1st, 2002 and Dec. 15th, 2002, we received survey papers about the dermographic characteristics and life styles and confirmed ABO blood type from the health screening receivers in NHIC Ilsan Hospital Health Promotion Center. In the 1255 cases who were tested the upper G-I series or fiberoptic gastroduodenoscope, we excluded the 184 cases that have gastric ulcer and duodenal ulcer at the same time or malignant ulcer in the histological examination or incomplete medical records. We analysed 1071 cases. We used STATA 5.0 statistical software and comparative analysis was done with Chi test or ANOVA test. Results : In the 1071 cases, gastric ulcer group was 84 cases and duodenal ulcer group was 59 cases. In the gastric ulcer group, sex ratio was 3.4 : 1 and male was the risk factor in statistical analysis. Age over 60 years old was 85.71%, but age was not the risk factor. In the gastric ulcer group, many cases were professional or clerical and the job was the risk factor. But marriage, education, religion and economic status were not the risk factors. Smoking, amount of smoking, alcohol drinking were the risk factors. But coffee, regular exercise, breakfast were not the risk factors. Development of gastric ulcer was not related to the gastroenteric symptoms, ABO blood type but related to the H. pylori infection because H. pylori infection was 74% in the gastric ulcer group. In the duodenal ulcer group, sex ratio was 3.5 : 1 and male was the risk factor. Age over 60 years old was 88.14%, but age was not the risk factor. In the duodenal ulcer group, many cases were housewives and job was the risk factor. But marriage, education, religion, economic status were not the risk factors. Smoking, amount of smoking, alcohol drinking were the risk factors. But coffee, regular exercise, breakfast were not the risk factors. Development of duodenal ulcer was not related to the gastroenteric symptoms, ABO blood type but related to the H. pylori infection because H. pylori infection was 87% in the duodenal ulcer group. Conclusions : The development of gastric ulcer was related to the sex, job, smoking, amount of smoking, alcohol drinking, H. pylori infection and the development of duodenal ulcer was related to the sex, job, smoking, amount of smoking, H. pylori infection.

Association between weekend warrior physical activity pattern and cardiometabolic risk factors in Koreans

감철민 서울시립대학교 도시보건대학원 2021 국내석사

ABSTRACT Background: Although studies have suggested an association between physical activity (PA) and beneficial health outcomes in weekend warriors who perform all their weekly exercises in one or two sessions, further studies are needed to confirm or refute if these previous findings are generalizable from a global perspective. Objective: To examine the association between the PA patterns of weekend warriors and cardiometabolic risk factors in a Korean population. Method: This cross-sectional study included 29,543 men and women aged 19 years and over who participated in the Korean National Health and Nutrition Examination Survey between 2014 and 2019. Weekend warrior PA was defined as 1 to 2 sessions of at least 150min/wk of moderate-intensity or at least 75min/wk of vigorous-intensity PA. We used logistic regression models to examine the association between weekend warrior PA and cardiometabolic risk factors. Results: About 2.8% of all participants were engaged in weekend warrior PA, of which 76.9% were men. Compared with the inactive PA pattern, the multivariable adjusted odds ratios (ORs) between weekend warrior PA pattern and several cardiometabolic risk factors were: 0.89; 95% CI: (0.69 to 1.15) for hypertension; 0.81; 95% CI (0.55 to 1.17) for diabetes; 0.92; 95% CI: (0.69 to 1.22) for dyslipidemia; 1.10; 95% CI: (0.91 to 1.34) for obesity; and 1.05; 95% CI: (0.83 to 1.27) for metabolic syndrome. In subgroup analysis by age group, there was a 43% reduced odds of hypertension after adjustment for sociodemographic and lifestyle variables in participants aged 60 years and above (OR: 0.57; 95% CI: 0.35 to 0.93). Conclusion: There was no significant evidence of associations between PA patterns of weekend warriors and several cardiometabolic risk factors in a Korean population. There might be protective effects on hypertension in older people, but large-scale cohort studies are needed to confirm these findings. Keywords: physical activity pattern, weekend warrior, cardiometabolic risk factors, health benefits 국문 초록 배경: 주당 150분 이상 신체활동 권장량을 하루나 이틀에 걸쳐 모두 수행하는 주말전사신체활동형태와 건강효과 간의 연관성을 시사하는 서구 연구들이 있으나 이런 결과들이 한국인에게도 적용될 수 있을지에 대한 연구가 필요하다 목적: 본 연구의 목적은 한국인에 있어 주말전사 신체활동형태와 심대사위험요인들과의 연관성을 조사하는것이다. 방법: : 본 연구는 2014년에서 2019년 사이 한국국민건강연구조사에 참여한 19세 이상의 성인 남성과 여성 29,543명을 대상으로 하였다. 국제신체활동질문지를 이용하여 신체활동량을 측정하였으며, 주말전사 신체활동형태는 일주일에 한 번 또는 두 번에 걸쳐 신체활동 권장량인 중등도 강도의 운동을 최소 150분 또는 격렬한 강도의 운동을 최소 75분 이상 하는 것으로 정의하였다. 통계방법은 로지스틱회귀분석모델을 사용하였다. 결과: 주말전사 신체활동 참여율은 약 2.8%였고 이들 중 남자가 77%였다. 잠재적인 교란변수를 보정한 뒤 주말전사 신체활동형태와 심대사위험요인들 사이의 승산비(Odds ratio)는 다음과 같다: 고혈압 OR: 0.89; 95% CI: (0.69 to 1.15); 당뇨병 OR: 0.81; 95% CI (0.55 to 1.17); 이상지질혈증 OR: 0.92; 95% CI: (0.69 to 1.22); 비만 OR: 1.10; 95% CI: (0.91 to 1.34); 대사증후군 OR: 1.05; 95% CI: (0.83 to 1.27). 그러나 연령대별로 세분화하여 실시한 하위분석에서 60세 이상의 주말전사 신체활동 참여자의 고혈압 승산비는 0.57(95% CI: 0.35 to 0.93)로 43%의 고혈압 위험도가 낮았다. 결론: 한국인에서 주말전사 신체활동형태를 가진 사람들의 비율은 매우 낮았다. 주말전사 신체활동형태와 심대사위험요인들 간의 유의한 연관성은 보이지 않았으나 60세 이상의 노인에서 고혈압의 위험도는 낮게 나타났다. 이런한 결과들을 확증하기 위해서는 대규모의 종단적 코호트 연구가 필요하다. 핵심어: 신체활동형태, 주말전사, 심대사위험요인, 건강유익

여성호르몬 노출 관련 유방암 발생 위험요인에 따른 유방암 검진 행태

진혜란 연세대학교 보건대학원 2016 국내석사

본 연구는 여성호르몬 노출관련 유방암 발생 위험요인 보유 여부에 따른 유방암검진 수검 행태와 그 관련 요인을 파악하기 위하여 제 5기(2010-2012년) 국민건강영양조사 자료를 분석한 단면연구이다. 유방암 위험요인으로 여성 호르몬 관련 요인이 잘 알려져 있으나, 기존 연구에서 이러한 위험요인 보유자들이 검진을 적극적으로 받고 있는지 보고된 바는 없는 실정이다. 여성호르몬 노출관련 유방암 발생 위험요인들이 이와 같이 명확하게 알려져 왔음에도 불구하고, 기존 연구에서는 일반적 사회경제적, 건강행동이 아닌 여성호르몬 노출관련 유방암 발생위험요인에 따른 고위험군 여성들의 검진 행동에 대한 분석을 찾기 어려웠다. 여성유방암의 생물학적 위험요인이 잘 알려져 있는 상황에서, 이렇듯 유방암 고위험군인 여성들이 조기검진을 잘 받고 있는지 여부는 사회적으로 암 관리 차원에서도 중요한 문제가 아닐 수 없다. 유방암 위험요인 중 여성 생식 관련 변수를 분석한 이미화(2014) 연구에서는 월경 여부, 여성호르몬제 복용 여부, 김영복(2000) 연구에서 초경연령, 자녀수, 모유수유경험과 조기검진 관련 분석이 이루어 졌으나, 본 연구는 국내 문헌고찰연구(장성미 등, 2012)에서 제시된 생식위험요인의 모든 변수를 포함하여 이미화(2014), 김영복(2000) 연구에 이른 초경, 늦은 폐경, 적은 출산횟수, 경구피임약 복용 변수를 추가하여 보다 포괄적으로 여성호르몬 노출 위험요인의 관련성을 추가 분석하여 여성 유방암의 위험요인 초경 연령, 폐경 연령, 첫 출산 연령, 임신횟수, 모유수유기간, 경구피임약 복용과 같은 유방암 위험요인 보유 여부와 보유 개수 에 따라 유방암 고위험군인 여성들이 실제로 검진을 잘 받고 있는지 알아보고자 한다. 이를 통해 개인의 유방암 위험요인 보유여부에 따른 검진이라는 미국질병관리특별위원회(U.S. Preventive Services Task Force, USPSTF) 검진 권고안에 대한 주의를 촉구하며, 우리나라 여성, 특히 유방암 고위험군의 유방암 수검률을 향상시키고, 효율적으로 유방암 사망과 비용을 감소시키는 정책을 개발하는데 필요한 기초 자료를 제공하고자 한다. 이에 본 연구에서 제 5기(2010-2012년) 국민건강영양조사를 바탕으로 한국에서 산출된 여성유방암 위험요인 중 이른 초경, 늦은 폐경, 적은 출산횟수, 늦은 첫 출산, 모유수유 미경험, 경구피임약 복용요인여부에 따른 유방암검진 수검 행태와 유방암검진 수검 관련 요인을 분석한 결과, 유방암검진 수검자 3,918(79.6%)명, 미수검자 1,001(20.4%)명 이었으며 연령은 40세 이상 평균연령 65.0세였다. 여성 유방암 위험요인 보유 개수와 유방암검진 미수검 관련성을 로지스틱 회귀분석을 통해 분석한 결과, 여성유방암 위험요인 2개 보유자(OR=1.50, 95%CI=1.01-2.23), 3개 보유자(OR=1.66, 95%CI=1.02-2.67)는 0개 보유자에 비해 미수검이 많은 것으로 나타났다. 연령 60-69세가 40-49세에 비해 유방암 검진 미수검이 적었고(OR=0.59, 95%CI=0.35-0.99), 교육수준에서는 초졸 이하가 대졸에 비해 유방암검진 미수검이 많으며(OR=1.56, 95%CI=1.05-2.31), 주관적 건강상태는 ‘보통’(OR=0.61, 95%CI=0.40-0.91)이 ‘매우 좋음’에 비해 유방암 미수검이 적고, 흡연여부는 ‘피움’이 ‘피우지 않음’에 비해 유방암 미수검이 많았으며(OR=1.96, 95%CI=1.13-2.75), 주관적 체형인식은 현재 본인의 체형이 어떻다고 생각하는지 판단한 물음에 대한 답변으로 ‘매우 마른편’이 ‘보통’에 비해 유방암 미수검이 많고(OR=1.31, 95%CI=1.01-1.71), 주관적 체형인식이‘약간 비만’이 ‘보통’에 비해 미수검이 적었다(OR=0.75, 95%CI=0.62-0.89). 여성 호르몬 관련 유방암 발생 위험요인 2~3개 보유자들은 유방암 발생 고위험군 임에도 불구하고 위험요인이 없는 군에 비해 유방암검진을 받지 않고 있다. 이들에게 유방암검진 참여를 독려할 수 있는 전략을 고려해 보고, 나아가 유방암고위험군 검진참여 개선이 유방암 사망감소 및 비용 절감에 기여할 수 있는지 향후 연구로 알아보아야 할 것이다. 유방암 조기 발견을 위해 권고에 따른 정기적인 유방암검진 유도메시지 개발에 있어, 유방암 위험관련 여성건강변수가 유방암검진 실행에 긍정적 결정을 유도할 수 있도록 유방암에 대한 본인이 가지고 있는 위험요인을 파악하고 예방행위를 실행하도록 수검에 장애 요소를 파악하고 이를 개선하는 중재가 필요하다고 생각된다. This study is a cross-sectional research that analyzed the 5th (2010-2012) Korean National Health & Nutrition Examination Survey to understand type of breast cancer screening and relevant factors according to the presence of breast cancer risk factors related to the exposure of female hormone. Although the factors related to female hormone have been well known as breast cancer risk factors, whether or not the holders of such risk factors have the screening actively has not been reported in the existing studies yet. Despite risk factors related to exposure of female hormone have been known clearly as above, it has been hard to find analyses in the existing studies on the high-risk women’s screening behavior according to the breast cancer risk factors related to the exposure of female hormone, not general socioeconomic and health behavior. In a situation that biological risk factors of female breast cancer has been well known, whether or not women belonging to the high-risk group take early screening is definitely an important question at the social cancer control level. In the study conducted by Lee (2014) that analyzed variables related to female reproduction out of breast cancer risk factors, menstruation and taking female hormone drugs, and Kim’s study (2000) conducted an analysis related to the age of the first menstruation, number of children, experience of breast-feeding and early screening, but this study aims to investigate whether or not women belonging to the group with high-risk of breast cancer takes screening actively according to the presence of breast cancer risk factors such as the age of the first menstruation, age of menopause, age of first childbirth, the number of pregnancy, period of breast-feeding, taking oral contraceptives and number of carrying by adding and analyzing relevance of exposure of female hormone to risk factors more comprehensively by adding variables such as early first menstruation, late menopause, small number of childbirth and taking oral contraceptives to the studies conducted by Lee and Kim including all variables of risk factors of reproduction suggested in domestic literature review (Jang et al., 2012). Through the foregoing, this study intends to call for attention to the USPSTF screening recommendation which is the screening depending on the individuals’ possession of breast cancer risk factors, improves Korean women’s, especially high-risk women’s breast cancer screening rate and provide preliminary data necessary for development of policies capable of reducing death and costs caused by breast cancer in an effective way. Thus, this study analyzed factors related to the type of breast cancer screening and breast cancer screening out of female breast cancer risk factors calculated in Korea based on the 5th (2010-2012) Korean National Health & Nutrition Examination Survey, and found that the number of examinees of breast cancer screening was 3,918(79.6%) and non-examinees was 1,001(20.4%) respectively, and the age was over 50 and average 65.0. Results of Logistic Regression Analysis on the relevance between the number of possession of female breast cancer risk factors and untaking of breast cancer screening show that untaking amongst 2 female breast cancer risk factors holders (OR=1.50, 95%CI=1.01-2.23) and 3 factors holders (OR=1.66, 95%CI=1.02-2.67) was higher as compared to the ones with 0 factor. The number of untaking of breast cancer screening was less in the group aged 60-69 (OR=0.59, 95%CI=0.35-0.99) comparing to 40-49, more (OR=1.56, 95%CI=1.05-2.31) in elementary graduates as compared to college graduates in education variable, less in ‘average’ (OR=0.61, 95%CI=0.40-0.91) comparing to ‘very good’ in subjective health condition variable, more (OR=1.96, 95%CI=1.13-2.75) in ‘smokers’ as compared with ‘non-smokers’ in smoking variable, and as answers to the question about one’s current body type, untaking of breast cancer screening was more (OR=1.31, 95%CI=1.01-1.71) in ‘very slim’ comparing to ‘average’, whereas less (OR=0.75, 95%CI=0.62-0.89) in ‘slightly obese’ comparing to ‘average’ with respect to subjective recognition of body type. Despite 2-3 breast cancer risk factors holders related to female hormone are the high-risk group, they take breast cancer screening less as compared to the group without risk factors. Future studies need to consider strategies capable of encouraging them to take part in the breast cancer screening, and investigate if improvement of high-risk group’s participation in breast cancer screening can contribute to the reduction of death and cost caused by breast cancer. In developing a message inducing to take regular breast cancer screening according to the recommendation for the early detection of breast cancer, understanding of elements becoming obstacle to taking screening and mediation to improve the foregoing are considered necessary for enabling women to understand one’s risk factors of breast cancer and carry out preventive behaviors for inducing women’s health variables related to the risk of breast cancer can induce a positive decision for execution of breast cancer screening.

AHP분석을 활용한 민간도시개발사업의 위험요인 분석에 관한 연구 : 환지방식을 중심으로

한원형 중앙대학교 대학원 2022 국내석사

In recent years, the large scale land development is being implemented through urban development projects based on the Urban Development Act. Particularly, numerous urban development projects are being carried out by private sectors through land Replotting approach. Although urban development participants of private sector prefer land replotting approach, it has a problem that it takes longer than other development approach due to various risk factors. With consideration of the problems, this study aims to identify risk factors of land replotting approach in private sector-led urban development projects and to figure out the priority of risk factors for every stage of development projects. To this end, Analytic Hierarchy Process (AHP) was used for this study and risk factors appearing in private sector-led urban development projects of land replotting approach were derived from reviewing preceding studies and having interviews with experts. In addition, a survey was conducted for urban development project experts based on the derived risk factors, and with this, the importance of development stages and risk factors for each participant was identified and priorities were determined. The results of this study are summarized as follows. First, as a result of analyzing the importance of development stages by each participant, it was found that local governments and landowners cooperatives had high importance in planning stages, and the business agencies in implementation stages. Through this, it was confirmed that there was a difference in the role importance of participants by each development stage. In addition, as a result of analyzing the importance of risk factors for each participant, 'designation cancellation due to incorrect legal procedures when designating a zone' for local governments, 'difficulty in procurement of project costs' for business agencies, 'lack executives and representatives with development knowledge' for landowners cooperatives, and 'suspension of construction due to civil complaints after construction starts' construction companies were found to be the most important risk factors. Second, as a result of comparative analysis by respondent group, it was found that there was no significant difference among respondent groups in the importance of development stages and risk factors of local governments and construction companies. On the other hand, in case of business agencies and landowners cooperatives, the importance of development stages and risk factors differed among respondent groups, which means that each participant has different perspectives on determining causes of a problem. This study suggests the following. First, the important risk factors of participants appeared in development stages in which the importance was high. Therefore, it is urgently necessary for each participant to discuss policies to improve the risk factors that appeared in the important development stages. Second, it is necessary for business agencies and landowners cooperatives to discuss how to resolved problems by comprehensively considering not only the self-diagnosed risk factors but also risk factors pointed out by participating experts. Third, when establishing a development plan, which is the initial stage of the project, a sufficient explanation of land replotting plan is required for landowners, and efforts are required to reach an agreement with landowners based on this. 오늘날 대규모 토지개발사업은 도시개발법에 근거한 도시개발사업을 통해서 개발되고 있으며, 다수의 도시개발사업은 환지방식을 활용한 민간시행자에 의해서 진행되고 있다. 이처럼 민간도시개발사업은 환지방식을 선호하고 있음에도 불구하고 다양한 위험요인들로 인해 여타 개발방식보다 장기간 소요되는 문제를 가지고 있다. 이와 같은 문제 인식하에 본 연구는 환지방식 민간도시개발사업에서 나타나는 위험요인을 파악하고, 참여 주체별로 개발단계 및 위험요인의 중요도를 분석하여 중요순위를 측정하고자 한다. 이를 위해 본 연구는 AHP분석(Analytic Hierarchy Process: AHP)을 활용하였으며, 우선 선행연구 검토와 전문가 인터뷰를 통해 환지방식 민간도시개발사업에서 나타나는 위험요인을 도출하였다. 또한, 도출된 위험요인을 통해서 도시개발사업 전문가들을 대상으로 설문조사를 진행하였으며, 이를 통해서 참여 주체별로 개발단계 및 위험요인의 중요도를 파악하고 중요순위를 선정하였다. 본 연구의 결과를 요약하자면 다음과 같다. 첫째, 참여 주체별 개발단계의 중요도 분석결과, 지방자치단체와 조합은 계획단계, 업무대행사는 시행단계에서 중요도가 높게 나타났다. 이를 통해서 개발단계별로 참여 주체의 역할 중요도는 차이가 있음을 확인하였다. 또한, 참여 주체별 위험요인의 중요도 분석결과, 지방자치단체는 ‘구역지정 시 잘못된 법적 절차로 인한 지정 취소’, 업무대행사는 ‘사업비 조달의 어려움’, 조합은 ‘개발지식을 갖고 있는 임원 및 대의원의 선출 부족’, 시공사는 ‘착공 후, 민원문제로 인한 공사중지’가 가장 중요한 위험요인으로 나타났다. 둘째, 응답자 그룹별 비교분석 결과, 지방자치단체와 시공사의 개발단계 및 위험요인의 중요도는 응답자 그룹 간에 큰 차이가 없는 것으로 나타났다. 반면 시행대행사와 조합의 경우, 개발단계 및 위험요인의 중요도는 응답자 그룹 간 차이가 있는 것으로 나타났으며, 이는 참여 주체 간에 문제의 원인을 바라보는 관점이 다르다는 것을 의미한다. 본 연구가 시사하는 바는 다음과 같다. 첫째, 참여 주체의 중요 위험요인은 중요도가 높게 나타난 개발단계에서 나타났다. 따라서 각 참여 주체는 중요 개발단계에서 나타난 위험요인을 개선하기 위한 정책적 논의가 시급하다. 둘째, 시행대행사와 조합은 자가 진단한 위험요인뿐만 아니라 그 외 참여 주체 전문가가 지적한 위험요인까지 종합적으로 고려하여 문제 개선을 위한 논의가 필요하다. 셋째, 사업의 초기 단계인 개발계획수립 시, 토지소유자를 대상으로 환지계획에 대한 충분한 설명이 필요하며 이를 토대로 토지소유자와 합의점을 도출하기 위한 노력이 요구된다.

심부전환자를 위한 퇴원간호서비스모델 개발

박성혜 연세대학교 대학원 2021 국내박사

1. Introduction The emphasis on medical cost efficiency of medical institutions has stimulated the reduction of hospital stay and early discharge policies to improve bed turnover. The related readmission management has become an important issue in terms of system efficiency of medical institutions, the quality of medical services provided, and medical costs. Heart failure (HF) was identified as the disease group with the highest readmission rate in tertiary hospitals in Korea for the past 10 years. The transition to an aging society requires management of chronic diseases, especially appropriate post-discharge management of HF patients with high readmission rates. The quality of discharge of a person who has been discharged from a hospital may be improved by reducing the length of stay, managing after discharge necessary for early discharge, and preventing risk factors for readmission. Therefore, this study developed a discharge nursing service model (DNSM) including high risk factors, the job standard of discharge nurses, and the overall discharge nursing process of high readmission rates and confirm clinical feasibility. 2. Objective The purpose of this study is to develop a DNSM for HF with high readmission rates, and the specific objectives are as follows. 1) Collect basic data for the development of a draft DNSM for HF patients. A) Through systematic literature review and electronic medical record (EMR) analysis, high-risk factors of HF readmission patients are derived. B) Develop job standards for discharge nurses who will provide discharge nursing services to patients with HF. C) Develop a discharge nursing process to reduce readmissions for HF. 2) Evaluate the validity of the DNSM based on the basic data. 3) Develop a final DNSM for HF patients. 3. Theoretical framework This study’s conceptual framework is based on Donabedian's Structure- Process-Outcome (SPO, 1998) model as a theoretical foundation for DNSM for HF. Structure aspects are defined as the physical environment and human resources, and process aspects are defined as treatment or diagnosis, prevention activities and education conducted on patients. Finally, outcomes are defined as patient achievements, such as health status, changes in behavior or knowledge for health, and patient satisfaction. In this study, the structure is defined as a high-risk factors for readmission of HF patients and job standards for discharge nurses derived through literature review and EMR analysis. The job standards for discharge nurses were implemented through systematic literature review and benchmarking of domestic and foreign medical institutions, and expert validity was checked. The process refers to the discharge nursing process, and consists of the activities of the discharge nurse, including nursing management, nursing diagnosis, nursing intervention, and nursing evaluation. The results indicate the effect of the DNSM on the patient's health status. In this study, it was defined as self-care behavior and readmission within 30 days of discharge of HF patients. 4. Research method 1) Research design This study is a methodological study that develops DNSM for HF with high readmission rates and confirms clinical validity. 2) Research process STEP 1. Development of a Draft DNSM for HF ① Selection of high risk factors for readmission of HF A) Identification of high risk factors for readmission of HF patients through literature review B) To verify the validity of high risk factors through the analysis of EMR data of HF patients who are hospitalized after being discharged from the hospital C) Presentation of a functional model of high risk factors for readmission of HF patients ② Development of job standards for discharge nurses A) Identification of specific roles of discharge nurses through literature review B) Verification of discharge nurses’ activities through benchmarking of domestic and foreign institutions C) Development of job standards (proposed) for discharge nurses ③ Development of discharge nursing process A) Discharge nursing process analysis through literature review B) Development of discharge nursing process STEP 2. Validation of DNSM for HF (Delphi) Validation of the feasibility of DNSM for HF was conducted by organizing a panel of experts to utilize Delphi techniques. Specialists for Delphi techniques should not exceed 3 to 10 (Lynn, 1985), before collecting the data, each expert was provided with information such as research topics, purpose, number of surveys, and anonymity by wire or mail to confirm her/his intention to participate and receive consent. Expert feasibility assessment uses the Content Value Index (CVI) and is interpreted to have obtained validity if the CVI is 0.78 or higher for each measurement item. The data collection was conducted by e-mail or printed questionnaires, with a total response rate of 100 percent from nine experts. The first Delphi data collection period was from 12 April to 12 May 2021, and the second Delphi data collection period was from 14 to 27 May 2021. STEP 3. Finalizations of DNSM for HF Based on the results of the practical suitability verification, such as content validity, the DNSM for patients discharged from the hospital with HF was finalized. 5. Research results STEP 1: Development of a draft DNSM for HF ① Selection of high risk factors for readmission of HF A total of 28 high risk factors for readmission of HF patients were identified through systematic literature review. A) Results of checking high risk factors for readmission of HF through literature review : Readmission high-risk factors for patients with severe HF, gender, age, economic status, income levels, hospitalization history, polypharmacy, over the past six months hospitalization with emergency room, severity, hyperlipidemia and depression, presence of chronic obstructive pulmonary disease (COPD), NYHA functional class, systolic blood pressure, left ventricular effusion coefficient, prescription of discharge medication for β-Blocker and ACEI/ARB, and Na and NT-proBNP blood test levels. B) Results of feasibility of high risk factors through EMR data analysis of HF patients who are hospitalized after being discharged from hospital : A total of 267 (14.4%) of 1,857 patients with HF was readmitted. Age (p=0.048), initial body weight at hospitalization (p=0.031), body weight change (p=0.009), and hospitalization for 6 months prior to hospitalization and emergency room visit (p<0.001), pulse rate (p=0.010), number of medications discharged (p<0.001), Hg (p<0.001), Hct (p<0.001), BUN (p=0.002), Na (p<0.001) level at admission, Hg (p<0.001), Hct (p<0.001), BUN (p=0.041), Na (p<0.001), CRP (p=0.043) level at discharge, main diagnosis of emergency room (p<0.001) and ACEI/ARB medication discharge prescription (p=0.025) were found to be significantly related to readmission. C) Functional model of high risk factors for readmission of HF : After confirming the validity of high-risk factors through EMR data analysis, multivariate logistic regression analysis was performed with explanatory variables with a p-value of less than 0.05 between the readmission group and the non-readmission group. As a result, for each increase in the number of discharge medications, the readmission odds ratio was 1.030 times, that is, the readmission rate increased by about 3.0% (p<0.001). For each increase in Na level at admission, a 5.4% decrease in readmission (OR=0.946, p=0.021), a 6.6% decrease in readmission for each increase in Na level at discharge (OR=0.934, p=0.028). For each increase in CRP level at discharge, readmission decreased by 1.1% (OR=0.989, p=0.049), and AUC was 0.735. ② Development of job standards for nurses in charge of discharge A) Results of identifying specific roles of nurses in charge of discharge through literature review : A total of 15 specific details of the job of nurses in charge of discharge were identified through systematic literature review. B) Results of verifying work activities through benchmarking of domestic and foreign discharge nurses' operating institutions : In Korea, all five general hospitals did not operate nurses exclusively for discharge. Overseas, team leaders from three U. S. hospitals, one in China, and one in Poland, who conducted research on the discharge care system for HF patients, explained the purpose of the study via e-mail and asked for data on job descriptions or role of discharge nurses. Among the five hospitals, one hospital in the U. S. and China responded, and in the U. S. one discharge nurse managed five HF during the study, but now one case manager managed about 30 to 50 patients with various diseases but failed to manage them after discharge. In the case of China, all HF nurses without discharge nurses were answered to provide discharge nursing services, and there was no written job description. C) Development of job standards for nurses in charge of discharge : The job standard (proposed) of a discharge nurse who is directly in charge of the discharge process of HF patients is the core competency of professional nursing practice suggested by Hamric et al. (2013) and the core competency and job scope of a professional nurse suggested by the Korean Nursing Association (2012). It was developed based on the core competency standards of professional nurses in the rapid response team developed by Lee (2019) by integrating the standard contents. The roles of the discharge nurse were identified as 28 work activities based on 9 core competencies: professional nursing practice, education, counseling, advice, ethical decision-making, research, collaboration, evidence-based practice, and leadership. The job standard (proposed) for discharge nurses was developed with 9 standards (proposed), 15 criteria (proposed), and 42 indicators (proposed) focusing on the identified tasks. ③ Development of discharge nursing process A) Results of analysis of discharge nursing process through literature review : The discharge nursing process was searched along with the job standard of discharge nurse. B) Development of discharge nursing process : The discharge nursing process is based on the structure, process, and outcomes of Donabedian, the theoretical framework, and is classified into five stages, from hospitalization to pre-discharge stage, discharge stage, post-discharge stage (telephone counseling and home visiting), outpatient care, and discharge care service termination. The goals for each stage, discharge nursing interventions for discharge nurses, and achievement indicators and evaluation tools for patients and main caregivers. STEP 2. Validation of DNSM for HF (Delphi) result ① General characteristics of expert panels The group of experts to investigate the validity of the DNSM were consisted of nine, two cardiologists, two nursing professors, two cardiovascular hospital wards and outpatient managers, one cardio nurse practitioner, one HF clinic nurse, and one cardio outpatient nurse. Clinical experience averages 14 years, and professors have an average of 13 years of teaching experience. Of the nine professionals are four doctors, four masters, and one bachelor's degree. With the exception of two nursing professors, the average length of work at a cardiovascular hospital was 11 years. ② Results of verification of validity of DNSM for HF This study achieved expert consensus on the discharge nurse's job standard and discharge nursing process of DNSM for HF twice content validity verification of Delphi experts. A) Results of verification of the validity of job standards, criteria, and indicators of discharge nurses : The roles of the discharge nurse were identified as 28 work activities based on 9 core competencies: professional nursing practice, education, counseling, advice, ethical decision-making, research, collaboration, evidence-based practice, and leadership. The job standard (proposed) for discharge nurses was developed with 9 standards (proposed), 15 criteria (proposed), and 42 indicators (proposed) focusing on the identified tasks. The developed job standard (proposed) was verified as having an average CVI of 0.94 by verifying its content validity using the Delphi technique conducted twice. B) Results of verification of validity of discharge nursing process : The discharge nursing process for HF patients was analyzed and integrated by time period from hospitalization to 30 days after discharge through systematic literature review. The discharge nursing process is divided into a total of 5 stages from hospitalization to pre-discharge stage, discharge stage, post-discharge stage (telephone counseling and home visiting), outpatient treatment, and discharge nursing service termination. The developed discharge nursing process was also verified for content validity using the Delphi technique of the expert group conducted twice, and the average CVI was found to be 0.92. STEP 3. Confirmation of final DNSM for HF High risk factors of the DNSM for HF, and the content validity verification result of the discharge nurse’s job standard (proposed) 9 standards (proposed), 15 criteria (proposed), 42 indicators (proposed) all had a CVI of 0.78 or higher. In the case of the discharge nursing process, it was confirmed that the CVI of all items was 0.78 or higher, and the DNSM was confirmed as follows <Figure 5>. 6. Discussion 1) Nursing problems related to high-risk factors for readmission of HF In order for the prevention and post-discharge management of readmission patients with high readmission rates to be successful, the identification, prevention and management of high risk factors that cause readmission must be carried out systematically. The rapid increase in the elderly population contributes to the social stimulus burden, including medical and social services, and the increase in health insurance benefits for senior citizens. In this study, more than 70% of hospitalized patients under diagnosis of HF were elderly patients, which is a result of the transition to an ultra-aged society and the absence of caregivers or care families. In the case of elderly patients, it is important to use easy terms in discharge education, provide audio-visual materials using pictures, photos, and repeat learning due to a decline in cognitive function. In this study, it can be seen that the period from discharge to readmission is an average of 14 days, and appropriate post-hospital care is required for two weeks after discharge. The effect can be expected if self-care training is conducted by discharge nurses before discharge from the hospital, and telephone counseling by discharge nurses and 1:1 retraining by home visiting nurses for two weeks after discharge. The average number of discharged medications for readmission HF is 23, indicating the importance of drug education for treatment and symptom management of HF. The importance of polypharmacy use, one of the reasons for the readmission of HF, has already been highlighted in prior studies. Therefore, it is essential to ensure that home visiting nurses are taking the medications accurately after discharge and to manage them later through retraining. Difficulty breathing, the main symptom of HF, will be identified as the chief complaint of emergency room, and education on prevention and symptom management will be important before and after discharge. The application of a program that includes telephone-based self-care training for at least two times a month for three months and self-care and readmission within 30 days of discharge for HF discharged from the emergency room. In this study, Hg and Hct levels in readmission HF averaged 11.4 g/dL and 34.7%, lower than 12.0 g/dL and 36.5% in patients without readmission (p<0.001). This is the same result of Chung’s (2008) studies in which readmission due to HF may be higher if Hg levels are above 17 g/dL or below 13 g/dL (the lower the levels of hemoglobin in patients with HF). BUN levels averaged 32.7 mg/dL in the readmission group, higher than 29.0 g/dL in the non-admission group. On the other hand, Na levels averaged 136.7 mmol/L in the readmission group, lower than 138.4 mmol/L in the non-admission group. This is equivalent to the results of low Na and high BUN levels affecting readmission in the Get With the Guidelines HF (GWTG-HF) program of the American Heart Association. Therefore, if selected for high-risk HF patients are hospitalized, regular blood tests should be conducted once a week through a home visiting nurse's visit up to two weeks after discharge to prevent readmission by managing the symptoms and signs of HF. Risk score for predicting 30-day HF-specific readmission developed by Lim et al. in 2019 is based on age, NYHA functional class, presence of hypertension, hospitalization in the previous 6 months, presence of COPD, presence of cardiomyopathy, presence of systolic blood pressure, left ventricular ejection fraction, β-Blocker and ACEI/ARB prescriptions for discharge, Na and NT-proBNP levels during blood tests are assigned scores for a total of 12 high-risk indicators. It is defined as a high risk of readmission. In this study, when the results of EMR data analysis were applied to Lim et al.'s tool, the indicators significantly related to readmission among 12 items were age (p=0.002), previous hospitalization for HF (p<0.001), and Cardiomyopathy (p=0.026), systolic blood pressure less than 110mmHg at discharge (p=0.018), without ACEI/ARB discharge medication prescription (p=0.021), Na<135mmol/L (p<0.001), BNP≧700 or NT-proBNP≧8,000 pg/mL (p=0.004), etc. in total. The total score was 12.6 on the average in the readmission group, and 10.6 in the non-readmission group, which was confirmed to be significantly related to readmission (p<0.001). If the reliability and validity of the Risk score for predicting 30-day HF-specific readmission tool developed by Lim et al. is proven through continuous research, it is applied to the EMR system and utilized as a high-risk factor function, standardized DNSM. It is considered that it can be connected to effective disease management through the application of the process and the management of home visiting nurses. 2) Identification of job standards and discharge nursing processes for discharge nurses In this study, discharge nurses will perform a combination of professional nursing practice, education, counseling, advice, ethical decision making, research, collaboration, evidence-based practice, and leadership. Based on the high risk factors of readmission, the DNSM is classified into five stages: pre-discharge, discharge, post-discharge (telephone counseling & home visiting), outpatient care, and discharge nursing service termination. In Korea, discharge nursing has been conducted by nurses or charge nurses on the day of discharge, not by certain personnel. However, the absence of standardized discharge nursing processes, such as nurses' preparation for discharge education and lack of relevant knowledge, may lead to inadequate post-discharge care and cause readmission. The effectiveness of discharge education on HF patients in this study showed positive results in self-care, including readmission prevention and symptom monitoring, adherence to medication, and low-sodium diets. Therefore, discharge nurses can be said to be responsible for providing sufficient education to patients and caregiver managing the disease after discharge. The discharge nursing process based on the job standards, criteria, and indicators of discharge nurses developed in this study could lead to successful role performance in the discharge process and improved prognosis for HF. In this study, out of a total of 1,857 HF patients admitted to a first-class general hospital over the past three years, a total of 90 HF counseling were conducted in outpatient areas. HF counseling training can be conducted multiple times for patients and caregivers as needed. Counseling is consist of hight, weight, body mass index (BMI), current medication, NYHA class, presence of or readmission of HF symptoms within the last 6 months, dyspnea, drinking, smoking, eating habits, awareness, daily adherence to HF medication. HF education has been shown to be highly associated with self-care in HFs, and nurse-led training has been effective in reducing readmission in HFs. The reason for the failure to expand HF counseling education is the lack of manpower to take charge of education. However, as suggested in the developed DNSM, if HF counseling is provided by discharge nurses prior to discharge, greater effect can be expected. After discharge, the actual HF counseling training was conducted from at least 6 days to 1,088 days, and the average number of readmission patients was 140 days after discharge and 110 days after no readmission occurred. As shown in the HF counseling training, this training should be conducted for patients and caregivers before discharge, not outpatient, so that post-discharge management can be efficient. After discharge, it can be linked to re-education and evaluation through home visiting nurses. In a study analyzing the relationship between the average length of stay in general hospitals and the level of nurse placement from 1996 to 2016, it was found that a decrease in the average number of days in hospital increased patient severity, nursing demand, and nursing intensity. Nurses working in wards with a short or medium length of stay had a faster work speed in order to solve a high nursing demand, and the higher the work demand, the more burnout, job satisfaction, and turnover intention increased. In order to solve this problem, if the discharge nursing process is carried out based on the job standards, criteria, indicators developed in this study, the discharge nursing process can be performed successfully in the discharge process of HF patients, as well as improving the prognosis of HF patients and treating HF patients. It can lead to effective nursing work performance through efficient division of duties among nurses in charge. 3) Application and expansion of the developed DNSM to the home management pilot project by Ministry of Health and Welfare HF itself has complicated pathogenesis and can cause complex problems depending on the severity of accompanying diseases such as diabetes (34.8%) and kidney diseases (33.3%). The extension of life expectancy will require proper management of patients with chronic diseases, and the Ministry of Health and Welfare will initiate a home care policy in 2019. The purpose of this policy is to provide medical institutions with periodic compensation for home care services through education, counseling, and regular monitoring of patients in need of continuous care. The home care pilot project aims to improve patients' quality of life and reduce medical expenditure by providing continuous management and feedback of home patients, as well as by improving public access to health care. The pilot project for at-home medical care for patients with heart disease is to provide medical services such as education, counseling, and monitoring to prevent worsening of diseases and improve the quality of life of patients with heart disease who require continuous management. Accordingly, it consists of calculating the appropriate level of educational counseling fees (face-to-face) and patient management fees (non-face-to-face). Of these, when a doctor or nurse provides counseling and education on how to use the device and self-management to heart disease patients (including their caregivers) visited by a doctor or nurse, the education consultation fee is calculated at KRW 24,810 (30 minutes or more per frequency, initial year: no more than 6 times a year, next year: up to 4 times a year) is possible. In addition, when a doctor or nurse checks the patient's condition at least once a month and provides a non-face-to-face management service for two-way communication such as checking the patient's condition using telephone calls or text messages, the patient management fee of KRW 26,610 can be calculated. The DNSM developed in this study is systematically managed from hospitalization to post-discharge of HF patients by a discharge nurse, and includes all the contents to be implemented in the at-home care pilot project for patients with heart disease. If there was difficulty in maintaining continuity of treatment because the existing discharge nursing was conducted by the patient's nurse or chief nurse on the day of discharge, the developed discharge nursing service is provided by the discharge nurse from the time of admission to the hospital for 30 days, up to 90 days after discharge continuous management is possible. In addition, it can be used as a basis for setting the number of nurses' education, counseling, continuous management and monitoring, and teach back. In this study, it is considered that high-quality management is possible according to a continuous treatment plan through management through a home visiting nurses. 4) Utilization of medical big data: Utilization of readmission high risk factors by improving the EMR system In the United States, about $25 billion is spent on preventable readmission, so it was attempted to predict readmission for HF patients and implement appropriate management through the establishment of a readmission prediction system combining EMR and Information Technology (IT). In a study by Bardhan et al., it was analyzed that the high risk factors for readmission for HF patients affects readmission according to the patient's personal information, hospital admission reason, insurance type, and hospital type. Medical big data, such as medical information in the medical information system and result data linked with test equipment, creates new medical information through integration and analysis. Medical big data built based on EMR should be utilized to create new values ​​as well as to generate various information for disease prevention and treatment. The high-risk factors for readmission presented in this study is classified as a high-risk HF patient by automatically applying and analyzing the EMR contents when a patient is hospitalized. Effective disease management should be achieved through. For this purpose, like the Risk score for predicting 30-day HF-specific readmission tool developed by Lim et al., a functional model that can predict the high risk of readmission with the total score should be established by scoring the relevant items of high-risk factors. In addition, the achievement indicators and evaluation tools of patients and their primary caregivers at each stage of the discharge nursing process should be reflected in the EMR system and used as basic data for future evaluation and research. This will maximize the utilization of medical big data through the improvement of the EMR system. It can be said that it is a matter that needs to be continuously discussed from the point of view that it is possible. 7. Conclusion In this study, the DNSM for patients with HF was based on the high risk factors for readmission, the job standard of the discharge nurses, and the result of the discharge nursing process was the performance of the HF patient's self-care behavior and readmission within 30 days after discharge. In terms of quality management, readmission is an important indicator, a result of patient care, and a major cause of medical cost increase, so it is necessary to develop an efficient system or service that can reduce it. The development of the DNSM in this study started with recognition of this problem and could be used as basic data such as job description of discharge nurses, preparation and evaluation of work guidelines, and development of discharge nurses curriculum. It is suggested that for the application of the DNSM, the establishment of the system along with the hospital's policy should precede, and that follow-up research should be carried out to examine its effectiveness in actual clinical sites. 의료기관의 의료비용 효율 강조는 병상회전율 향상을 위한 재원일수 단축과 조기퇴원 정책을 활성화시켰다. 이와 연관된 재입원 관리는 의료기관의 시스템 효율성, 제공된 의료서비스 질, 의료비용 측면에서 중요한 이슈가 되었다. 최근 10년 동안 우리나라 상급종합병원에서 가장 높은 재입원을 보이는 질환군은 심부전으로 확인되었다. 초고령화 사회로의 변화는 만성질환 관리, 특히 재입원율이 높은 심부전환자의 적절한 퇴원 후 관리가 필요하게 되었다. 이에 본 연구에서는 재입원율이 높은 심부전환자의 고위험지표, 퇴원전담간호사의 역할, 퇴원간호과정의 전반적 내용을 포함한 퇴원간호서비스모델을 개발하고 임상적 타당성을 확인하고자 한다. 본 연구는 방법론적 연구로 1단계 심부전환자를 위한 퇴원간호서비스모델 초안 개발은 체계적 문헌고찰과 전자의무기록 분석을 통한 심부전 재입원환자의 고위험지표 도출, 심부전환자에게 퇴원간호서비스를 제공할 퇴원전담간호사의 직무표준 개발, 심부전환자의 재입원 감소를 위한 퇴원간호과정으로 구성되어있다. 2단계는 심부전환자를 위해 개발된 퇴원간호서비스모델 초안의 타당도 평가로 전문가 집단의 델파이 기법을 통하여 평가가 진행되었다. 마지막 3단계에서는 최종 심부전환자를 위한 퇴원간호서비스모델 개발이 완성되었다. 연구 결과 문헌고찰을 통해 도출된 심부전환자의 재입원 고위험지표는 최근 3년간 일 상급종합병원에 심부전 진단 하 입원 후 퇴원한 환자의 전자의무기록 자료 분석을 통하여 그 타당성을 확인하였다. 심부전 퇴원환자 1,857명 중 재입원 환자는 총 267명(14.4%)이었으며 나이(p=0.048), 입원 시 최초 체중(p=0.031), 입원기간 동안 체중변화(p=0.009), 입원 이전 6개월 동안의 입원과 응급실 내원 여부(p<0.001), 맥박수(p=0.010), 퇴원약의 개수(p<0.001), 입원 시 Hg (p<0.001), Hct (p<0.001), BUN (p=0.002), Na (p<0.001) 수치, 퇴원 시 Hg (p<0.001), Hct (p<0.001), BUN (p=0.041), Na (p<0.001), CRP (p=0.043) 수치, 응급실 내원 시 주진단명(p<0.001), ACEI/ARB약물의 퇴원약 처방(p=0.025) 등이 재입원과 유의한 연관성이 있는 것으로 나타났다. 전자의무기록 자료 분석을 통하여 재입원 고위험지표의 타당성 확인 후 재입원군과 재입원이 발생하지 않은 군간 p값이 0.05 미만인 설명변수들로 다변량 로지스틱 회귀분석을 시행한 결과 퇴원약의 개수가 1개 증가할 때마다 재입원 오즈비가 1.030배, 즉 재입원이 약 3.0% 증가하는 것으로 나타났다(p<0.001). 입원 시 Na 수치가 증가할 때마다 재입원은 5.4% 감소(OR=0.946, p=0.021), 퇴원 시 Na 수치가 증가할 때마다 재입원은 6.6% 감소(OR=0.934, p=0.028), CRP 수치가 증가할 때마다 재입원은 1.1% 감소(OR=0.989, p=0.049)하는 것으로 나타났으며 AUC는 0.735였다. 선행연구와 문헌을 기반으로 퇴원전담간호사의 업무는 9개 핵심역량인 전문적 간호실무, 교육, 상담, 자문, 윤리적 의사결정, 연구, 협동, 근거기반 실무, 리더십에 따른 28개의 업무활동으로 구성하였다. 퇴원전담간호사의 직무표준(안)은 규명된 업무를 중심으로 9개의 표준(안), 15개의 기준(안), 42개의 지표(안)으로 개발되었다. 개발된 직무표준(안)은 두 차례에 걸쳐 진행된 델파이 기법으로 내용타당도를 검증, 평균 CVI는 0.94로 확인되었다. 심부전환자의 퇴원간호과정은 체계적 문헌고찰을 통하여 입원 시부터 퇴원 후 30일까지 심부전환자에게 필요한 퇴원간호중재 내용을 시기별로 분석, 통합하였다. 퇴원간호과정은 시기별로 입원 시부터 퇴원 전 단계, 퇴원 시, 퇴원 후 단계(전화상담과 가정방문), 외래진료 및 퇴원간호서비스 종료의 총 5단계로 분류되며 총 25개 항목의 퇴원간호과정으로 구성되었다. 개발된 퇴원간호과정 역시 두 차례에 걸쳐 진행된 전문가집단의 델파이 기법으로 내용타당도를 검증, 평균 CVI는 0.92로 확인되었다. 본 연구에서 심부전환자를 위한 퇴원간호서비스모델은 재입원 고위험지표와 퇴원전담간호사의 직무표준이라는 구조를 바탕으로 퇴원간호과정을 거쳐 심부전환자의 자가간호 행위 이행도와 퇴원 후 30일 이내 재입원이라는 결과를 평가할 수 있도록 개발되었다. 의료의 질 관리 측면에서 재입원은 중요한 지표이며 동시에 환자진료의 결과이자 의료비 증가의 주요 원인으로, 이를 감소시킬 수 있는 효율적인 시스템 또는 서비스의 개발이 필요하다. 본 연구를 통해 개발된 퇴원간호서비스모델은 지속적인 수정과 보완 작업을 거쳐 퇴원전담간호사의 업무지침서 작성 및 평가, 교육과정 개발, 그리고 퇴원간호중재 적용을 위한 기초자료로 활용될 수 있을 것이다.

A study on the dynamic relationship of the risk factors of homelessness

지은구 City University of New York 2002 해외박사

What is the most crucial determinant of homelessness? Is there any order among the risk factors to explain becoming homeless? Although there are many studies about the number, cause, or the personal characteristics of homeless people, the studies focusing on the dynamic relationships between variables to explain becoming the homeless are few. This study is a quantitative assessment of the influence of risk factors on the rates of homelessness. Correlations among these factors and homelessness rates precede multiple regression analysis. The objectives of this correlation analysis are to obtain values that indicate the relationships between risk factors and to determine if a relationship exists between risk factors. In order to describe the further nature of the relationships and to assess the degree of accuracy of prediction achieved by the regression equation, regression analysis was used to assess the relative importance of the risk factors in their contribution to variation in the rates of homelessness. The findings of this multiple regression study that employed three major models show that the poverty rate, among structural/societal risk factors, is strongly associated with homeless rate in model I. Individual risk factors explaining the cause of homelessness do not have correlations with homelessness and do not affect homelessness in model II. The rate of AFDC recipients was the only factor among ten indicators including individual and societal/structural risk factors that was highly correlated and associated with a high level of homelessness in model III. The findings of this study provide meaningful considerations for policy. First, policy makers focus not only on particularly psychological or individual issues of alcohol and drug abuse and mental health of homeless people, but also on the root causes of homelessness such as permanent poverty, economic conditions, a low level of welfare benefits, or the lack of affordable housing units drawn from societal/structural bases. Second, the findings of the study indicate that the reducing poverty rate is the priority in reducing the number of homeless people. Third, policy makers should identify that TANF families with no extra earnings are the most vulnerable subgroup for becoming homeless.

The Incidence, risk factors and viral etiologies of influenza-like illness in a community : A prospective cohort study in a district in seoul

이민혜 고려대학교 대학원 2015 국내박사

Objectives: This study was designed to prospectively observe a cohort of all age groups in a community in the Republic of Korea. The goals of the study were as follows: to determine the incidence and age-specific risk ratios (RR) of influenza and influenza-like illness (ILI), to determine age-stratified ILI risk factors for each of the non-adult (<20 years old) and adult (≥20 years old) groups, and to confirm the viral etiologies of ILI. Methods: A prospective cohort study was conducted from December 2012 to July 2014. The subjects included approximately 1,000 residents of Seongbuk-gu, Seoul, defined as those ≥6 months of age who were living in the community in residential houses with more than two family members. Baseline surveys and relevant data for influenza and ILI were collected. The study period was divided into two phases: Phase I lasted from January to October 2013 and Phase II lasted from November 2013 to July 2014. A total of 1,223 subjects participated in the study. The numbers of subjects participating in Phases I and II were 1,027 and 1,032, respectively, and some individuals were involved in both phases. The baseline studies investigated participants' demographic and household characteristics, lifestyle habits, preventive health behaviors, and underlying diseases. All subjects were evaluated every week to determine whether they had contracted ILI. Subjects with ILI were defined as individuals who showed fever or feverishness and cough or throat pain. When ILI was confirmed, a nasopharyngeal and nasal swab specimen was collected from the relevant subject and was tested by using real-time PCR assay for a panel of 14 respiratory viruses. All statistical analysis was based on the data from the Statistics Office and was weighted against the Seongbuk-gu ratios of gender and age per year. Poisson regression was performed for the RR calculation. Results: During Phase I, ILI incidence was 10.28 (cases/1,000person- week), and the incidence of influenza was 0.62 (cases/1,000person- week), or 6.03% of the ILI incidence. During Phase II, the incidence of ILI was 16.80 (cases/1,000person-week), and the incidence of influenza was 1.14 (cases/1,000person-week), or 6.79% of the ILI incidence. Compared to Phase I, Phase II showed higher incidences for both ILI and influenza. For the age-specific RRs, the group between the ages of 0 and 4 years was shown to be more at risk for ILI than the other age groups (p<0.001), and it was at a higher risk for influenza than those aged 20 and older (p<0.05). Among the ILI risk factors, exposure to non-direct smoking was found to be a risk factor for the non-adult group (p<0.001). For the adult group, risk factors were being female and married, living with more than five family members, being exposed to non-direct smoking, and pneumonia history. Such factors as an education level of middle school or above, heavy drinking (more than 5 drinks), handwashing for more than 10 seconds, and gargling for longer than 30 seconds were associated with lower ILI risks. Out of a total of 1,540 ILI specimens collected, 483 (31.36%) samples showed evidence of at least one of 14 respiratory viruses, and the co-infection rate was 8.49%. The most frequently detected viruses (in decreasing frequency) were hRv in 175 specimens (32.35%), hMPV in 71 (13.12%), influenza A in 67 (12.38%), influenza B in 40 (7.39%), hCoV-229E in 37 (6.84%), RSV B in 28 (5.18%), ADV in 27 (4.99%), hBoV in 26 (4.81%), hCoV-NL63 in 25 (4.62%), hCoV-OC43 in 23 (4.25%), PIV2 in 8 (1.48%), RSV A in 6 (1.11%), PIV3 in 6 (1.11%), and PIV1 in 2 (0.37%). The largest number of viruses was detected in samples from the 0-4 age group. When analyzed according to seasonality, the influenza virus and hCoV were more prevalent in winter, hRV and hMPV in spring, and hBoV in autumn. By contrast, hRV and hMPV were observed all year round. Conclusions: This study is of great significance, as it is the first Korean community-based prospective influenza cohort study to follow up with and observe all age groups and to be conducted for two consecutive terms. The results confirmed that those aged 0-4 years were the most at risk for ILI occurrence among all age groups, and they had the largest number of detected respiratory viruses. Furthermore, this study indicates that respiratory virus infections are seasonal. These findings will ultimately provide fundamental data required for future efforts to develop measures to prevent and deal with influenza-associated respiratory illness.