Effect of Repeated Public Releases on Cesarean Section Rates

장원모,은상준,이채은,김윤 대한예방의학회 2011 Journal of Preventive Medicine and Public Health Vol.44 No.1

Objectives: Public release of and feedback (here after public release) on institutional (clinics and hospitals) cesarean section rates has had the effect of reducing cesarean section rates. However, compared to the isolated intervention, there was scant evidence of the effect of repeated public releases (RPR) on cesarean section rates. The objectives of this study were to evaluate the effect of RPR for reducing cesarean section rates. Methods: From January 2003 to July 2007, the nationwide monthly institutional cesarean section rates data (1 951 303deliveries at 1194 institutions) were analyzed. We used autoregressive integrated moving average (ARIMA) time-series intervention models to assess the effect of the RPR on cesarean section rates and ordinal logistic regression model to determine the characteristics of the change in cesarean section rates. Results: Among four RPR, we found that only the first one (August 29, 2005) decreased the cesarean section rate (by 0.81 percent) and continued to have an impact period through the last observation in May 2007. Baseline cesarean section rates (OR, 4.7; 95% CI, 3.1 to 7.1) and annual number of deliveries (OR, 2.8; 95% CI, 1.6 to 4.7) of institutions in the upper third of each category at before first intervention had a significant contribution to the decrease of cesarean section rates. Conclusions: We could not found the evidence that RPR has had the significant effect of reducing cesarean section rates. Institutions with upper baseline cesarean section rates and annual number of deliveries were more responsive to RPR.

고관절 부분 치환술 시술정보 공개에 따른 재입원율, 입원일수 및 진료비의 변화

장원모,은상준,사공필용,이채은,오무경,오주환,김윤,Jang, Won-Mo,Eun, Sang-Jun,SaGong, Pil-Young,Lee, Chae-Eun,Oh, Moo-Kyung,Oh, Ju-Hwan,Kim, Yoon 대한예방의학회 2010 Journal of Preventive Medicine and Public Health Vol.43 No.6

Objectives: We assessed impact of performance reporting information about the readmission rate, length of stay and cost of hip hemiarthroplasty. Methods: The data are from a nationwide claims database, National Quality Improvement Project database, of Health Insurance Review & Assessment Service in Korea. From January 2006 to April 2008, we received information of length of stay, readmission within 30 days, cost of 22 851 hip hemiarthroplasty episodes. Each episodes has retained the diagnoses of comorbidities and demographics. We used time-series analysis to assess the shifting of patients selections, between high volume (over 16 operations in a year) and low volume institutions, after performance reporting (December 2007). The changes of quality (readmission, length of stay) and cost were evaluated by multilevel analysis with adjustment of patient's factors and institutional factors after performance reporting. Results: As compared with the before performance reporting, the proportion of patients who choose the high volume institution, increased 3.45% and the trends continued 4 months at marginal significance (p = 0.059). After performance reporting, national average readmission rate, length of stay were decreased by 0.49 OR (95% CI=0.25 - 0.95) and 10% (${\beta}$=-0.102, p<0.01) and cost was not changed (${\beta}$=-0.01, p=0.27). The high volume institutions were more decreased than low volume in length of stay. Conclusions: After performance reporting, readmission rate, length of stay were decreased and the patient selections were marginally shifted from low volume institutions to high volume institutions.

Social Distancing and Transmission-reducing Practices during the 2019 Coronavirus Disease and 2015 Middle East Respiratory Syndrome Coronavirus Outbreaks in Korea

장원모,Deok Hyun Jang,이진용 대한의학회 2020 Journal of Korean medical science Vol.35 No.23

Background: The absence of effective antiviral medications and vaccines increased the focus on non-pharmaceutical preventive behaviors for mitigating against the coronavirus disease 2019 (COVID-19) pandemic. To examine the current status of non-pharmaceutical preventive behaviors practiced during the COVID-19 outbreak and factors affecting behavioral activities, we compared to the 2015 Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in Korea. Methods: This was a serial cross-sectional population-based study in Korea with four surveys conducted on June 2 and 25, 2015 (MERS-CoV surveys), and February 4, and April 2, 2020 (COVID-19 surveys). Of 25,711 participants selected using random digit dialing numbers, 4,011 participants (aged ≥ 18 years) were successfully interviewed, for the 2020 COVID-19 (n = 2,002) and 2015 MERS-CoV (n = 2,009) epidemics were included. Participants were selected post- stratification by sex, age, and province. The total number of weighted cases in this survey equaled the total number of unweighted cases at the national level. We measured the levels of preventive behaviors (social distancing [avoiding physical contact with others]), and practicing transmission- reducing behaviors such as wearing face mask and handwashing. Results: Between the surveys, respondents who reported practicing social distancing increased from 41.9%–58.2% (MERS-CoV) to 83.4%–92.3% (COVID-19). The response rate for the four surveys ranged between 13.7% and 17.7%. Practicing transmission-reducing behaviors (wearing face masks and handwashing) at least once during COVID-19 (78.8%, 80.2%) also increased compared to that during MERS-CoV (15.5%, 60.3%). The higher affective risk perception groups were more likely to practice transmission-reducing measures (adjusted odds ratio, 3.24–4.81; 95 confidence interval, 1.76–6.96) during both COVID-19 and MERS-CoV. Conclusion: The study findings suggest markedly increased proportions of non- pharmaceutical behavioral practices evenly across all subgroups during the two different novel virus outbreaks in Korea. Strategic interventions are needed to attempt based on preventive behavior works

성인 자폐성장애의 규모 추정의 문제점: 가용 가능한 자료원의 비교를 중심으로

이진용,장원모,윤지은 한국장애인재활협회 부설 재활연구소 2019 재활복지 Vol.23 No.2

Because autism spectrum disorder (ASD) is a life-long disabiltiy, it is important to care children as well as adults. We analyzed the scale and time trends of adults in ASD. Data were collected from all the three databases, the National disability Registry (NDR), National Survey of Persons with Disabilities (NSPD), National Health Insurance (NHI) claims data in 2008, 2011, 2014, 2017. Number of adults in ASD were 4,792~9,617 in 2017. The difference between databases had increased from time. Number of adults in ASD had decreased from time in Older than 20. The decrease in 20-29 and 30-39 was the largest and Older than 30 had occupied average 3.7% of all ages of ASD. It was not found the cliff of the number of people from 20 years or older in intellectual disability. The number of younger than 19 rose 0.3-0.6 times, while the number of older than 20 increased 0.7-4.6 times for 9 years. Older than 20 accounted for 24.9~41.1% of total in 2017. We have a double problem that underestimation and rapid increasing in numbers of adults ASD. Improvement of surveillance system is needed for providing appropriate services to adults on ASD. 자폐성장애는 전 생애에 걸쳐 지속되기 때문에 소아․청소년뿐만 아니라 성인의 치료 및 돌봄까지중요하다. 성인 자폐성장애인의 규모 추계 및 시간에 따른 추이 분석을 시도하였다. ≷장애인현황≸, ≷장애인실태조사≸, 건강보험 청구 자료를 활용하여 연령별 자폐성장애인 수 규모를 추계하였다. 세자료원 모두가 생산된 2008, 2011, 2014, 2017년을 대상으로 분석하였다. 연구결과 첫째, 20세 이상 자폐성장애인 수는 4,792~9,617명(2017)이었으며 시간에 따라 자료원간 값의 차이는 증가하였다. 둘째, 20세 이상에서는 세 자료원 모두 연령증가에 따라 자폐성장애인 수는 지속적으로 감소하였다. 20~29 세 및 30~30세에서 인원수 감소폭이 가장 컸으며 30세 이상은 전 연령의 평균 3.7%를 차지하였다. 셋째, 20세 이상부터 발생하는 급격한 감소는 같은 발달장애 범주 안에 있는 지적장애에서는 발견되지 않았다. 넷째, 19세 이하 자폐성장애인수는 9년간 0.3~0.6배 증가한 반면 20세 이상에서는 0.7~4.6배 증가하였다. 2017년에는 20세 이상 인원수가 전체에서 24.9~41.1%를 차지하였다. 성인 자폐성장애인 규모는 빠르게 증가하고 있지만 여전히 과소 추계 되었을 가능성이 높다. 그 이유는 오(誤)등록, 미(未) 등록, 미(未)진단 등일 수 있다. 그러나 성인 자폐성장애인의 정확한 규모를 알 수 있는 자료원이 없다는 것을 확인하였다. 과거에 잃어버렸던 오등록 성인 자폐성장애인과 아직 등록하지 않은 이들, 그리고 진단기준의 확대 및 정확도의 향상으로 발견될 이들을 고려한 조사체계의 개선이 시급하다.

Korean National Health Insurance Value Incentive Program: Achievements and Future Directions

김선민,장원모,안현아,박향정,안혜숙 대한예방의학회 2012 Journal of Preventive Medicine and Public Health Vol.45 No.3

Since the reformation of the National Health Insurance Act in 2000, the Health Insurance Review and Assessment Service (HIRA) in the Republic of Korea has performed quality assessments for healthcare providers. The HIRA Value Incentive Program (VIP), established in July 2007, provides incentives for excellent-quality institutions and disincentives for poorquality ones. The program is implemented based on data collected between July 2007 and December 2009. The goal of the VIP is to improve the overall quality of care and decrease the quality gaps among healthcare institutions. Thus far, the VIP has targeted acute myocardial infarction (AMI) and Caesarian section (C-section) care. The incentives and disincentives awarded to the hospitals by their composite quality scores of the AMI and C-section scores. The results of the VIP showed continuous and marked improvement in the composite quality scores of the AMI and C-section measures between 2007 and 2010. With the demonstrated success of the VIP project, the Ministry of Health and Welfare expanded the program in 2011 to include general hospitals. The HIRA VIP was deemed applicable to the Korean healthcare system,but before it can be expanded further, the program must overcome several major concerns, as follows: inclusion of resource use measures, rigorous evaluation of impact, application of the VIP to the changing payment system, and expansion of the VIP to primary care clinics.

코로나19 유행 시기의 사망과 의료 이용 변화에 대한 탐색적 연구

신민선,이풍훈,장원모 건강보험심사평가원 심사평가연구소 2021 연구보고서 Vol.2021 No.0

From January to September 2020, Korea experienced the first and second waves of COVID-19 cluster infection in Daegu and North Gyeongsang province (February to March) and Seoul Metropolitan area (August to September). However, there was not enough evidence for policy measures due to lack of systematic analysis on the impact of COVID-19 to public health. This study aims to identify the magnitude of excess deaths and deprived utilization of health care. Based on data from 2010 to 2019, the gaps between estimated and actual deaths and utilization of health care in 2020 were calculated. In order to understand excess deaths and deprived utilization of health care, Quasi-poisson regression model was built in consideration of year, season, and other factors. Deaths and utilization of health care data during severe outbreak period were identified by total, gender, age, and region. According to the result, there was no excess deaths from January to September 2020. When compared against the model design, there was a reduction of 1,638 in death, but it was not statistically significant. There was no excess deaths by gender, but those between 20 to 34 showed 15.4% of excess deaths compared against estimation. In Daegu and North Gyeongsang province, there were excess deaths in March and August, and COVID-19 related deaths were concentrated around March and April. In regards to utilization of health care, reduction was detected between February to September in all areas of health care utilization compared against estimation. The greatest fall was observed in emergency room visit (28.0%), followed by inpatients (17.6%), outpatient (15.4%), and ICU admission (9.8%). While the level of fall differed upon service type (inpatient, outpatient, emergency room, ICU), the biggest gaps between estimation and actual were observed in March and September 2020. Gender gap was not significant across all service types, and reduction rate was higher among age 19 and younger and Daegu and North Gyeongsang province region. There is a need for more accurate and faster measurement methodology for excess deaths as it is an important indicator in understanding impact of infectious disease outbreak. Going forward, it is required to build an automated healthcare data infrastructure that can check and predict excess deaths and decreased health care utilization on a real-time basis in case of similar healthcare crisis.

의료기관 대상 코로나19 재정지원 제도의 효과 평가: 심층 인터뷰 결과를 중심으로

윤은지,안보령,고혜진,장원모,이진용 한국의료질향상학회 2023 한국의료질향상학회지 Vol.29 No.1

Purpose: The government of the Republic of Korea funded more than ￦15 trillion to healthcare providers to counter COVID-19. This study was conducted to examine the perception of the government funding program; to analyze it; and to explore its future direction to better prepare for upcoming pandemics. Methods: In-Depth Interview (IDI) was carried out of 16 subjects including doctors, policymakers, and professors from 7th June to 13th July 2021. Results: Every participant agreed that the subsidy made a huge contribution to preventing providers from bankruptcy and to stopping a collapse of healthcare system during the pandemic. However, different views occurred in the range of reimbursement. Providers recognized that it should have covered opportunity costs, extra expenses, and financial damage during the pandemic recovery. Whereas, the government perceived that the COVID-19 grant was enough to offset their financial damages. For future responses, most participants admitted that the program should be enhanced to be highly responsive to future pandemics. The standard of reimbursement needs to be eased to raise the funding rates; to reimburse more hospitals; and increase the compensation period and range. Conclusion: A pandemic like COVID-19 is highly likely to emerge more often forward. In a better response to future pandemics, it’s required to level up disaster response capability; to keep healthcare services well-functioning during the emergency; and restructure healthcare system to be resilient even after the pandemic. To this end, an increase in subsidies should be positively reviewed.

병원의 급성심근경색증 진료 결과 공개의 효과

은상준,김윤,이은정,장원모,Eun, Sang Jun,Kim, Yoon,Lee, Eun Jung,Jang, Won Mo 한국의료질향상학회 2011 한국의료질향상학회지 Vol.17 No.1

Objectives : The purpose of this study was to determine whether the published AMI report card could reduce in-patient mortality, 7-day after discharge mortality, and length of stay (LOS). Methods : Interrupted time-series intervention analysis was used to evaluate the impact of the report card for AMI care quality in November 2005 in terms of risk-adjusted in-patient mortality, risk-adjusted 7-day after discharge mortality, and DRGs case-mix LOS using the claim data of Health Insurance Review and Assessment Service. Results : Public disclosure of AMI care quality decreased risk-adjusted in-patient mortality and DRGs case-mix LOS by 0.00050% per month and 0.042 days per month respectively, however there was no effect on risk-adjusted 7-day after discharge mortality. Patterns of effect of public disclosure on AMI outcomes were a fluctuating pattern on risk-adjusted mortalities and a pulse impact for 1 month on DRGs case-mix LOS. Conclusions : We found the public disclosure of AMI care quality had decreasing effects on risk-adjusted in-patient mortality and DRGs case-mix LOS, but the size of the effect was marginal.

지방자치공청회 지상중계 ( 2 ) 인천지역공청회

장석례,김형희,백철현,심덕기,이백자,노창현,전용수,장원모,윤석제,장재근 대한지방행정공제회 1986 地方行政 Vol.35 No.394

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Chasms in Achievement of Recommended Diabetes Care among Geographic Regions in Korea

조상현,신지연,김현주,은상준,강성찬,장원모,정혜민,김윤,이진용 대한의학회 2019 Journal of Korean medical science Vol.34 No.31

Background: Although effective care for type 2 diabetes (T2DM) is well known, considerable inadequate care has been still existed. Variations in achievement of the recommended quality indicators inT2DM care among small areas are not well known in Korea. This study examined the quality of care T2DM care and its geographical variations. Methods: We used the national health insurance database and national health screening database. Seven quality indicators were used to evaluate continuity of care (medication possession ratio), process of care (hemoglobin A1c test, lipid profile, microalbuminuria test, and eye examination), and intermediate outcome (blood pressure control, and low-density lipoprotein control). Crude and age-standardized proportions were calculated for each 252 districts in Korea. Results: All quality indicators failed to achieve the recommended level. Only about 3% and 15% of the patients underwent eye examination and microalbuminuria test, respectively. Other indicators ranged from 48% to 68%. Wide variation in the quality existed among districts and indicators. Eye examination and microalbuminuria test varied the most showing tenfold (0.9%–9.2%) and fourfold (6.3%–28.9%) variation by districts, respectively. There were 32.4 and 42.7 percentage point gap between the best and the worst districts in hemoglobin A1c test and blood pressure control, respectively. Conclusion: Considerable proportion of T2DM patients were not adequately managed and quality of care varied substantially district to district. To improve the quality of diabetes care, it is necessary to identify the poor performance areas and establish a well-coordinated care system tailored to the need of the district.