생애 전주기적 만성질환 관리를 위한 질병모델 및 환자 중심 가이드 연구

초록

1. 지역사회 기반 만성질환 예방관리 수행체계 마련 고당등록관리사업의 효과를 의료체계, 의료이용, 건강행태, 사망률로 나누어 살펴 보았다.의료체계에 미치는 효과에서는 일단 환자들이 처음 등록한 의료기관과 약국에만 가는 경향이 강해져 단골의사와 단골약사가 생겨 우리나라 의료전달체계에 순기능을 수행하는 것으로 보인다. 이 점을 2012년 OECD 전문가들도 한국 의료체계의 질평가 보고서에서 언급하고 있다. 의료이용 측면에서 고당등록관리사업을 하지 않는 지역에 비해 의료기관 방문 횟수가 1회 더 많고 치료순응도가 증가하였으며 이로 인해 합병증으로 인한 입원율이 감소하고 사망률도 감소한 것으로 나타났다. 건강행태 측면에서는 고당등록사업을 하는 지역에서 65세 노인들의 경우 타 지역 노인들에 비해 교육경험이수율, 혈압 및 혈당 인지율, 합병증 검사 수검율이 더 높은 것으로 나타났으며 일부 지역에서는 뇌졸중과 허혈성심장질환의 조기증상 인지도가 높은 것으로 나타났다. 셋째, 사망률의 경우 특정 연도에 등록자군을 5년간 추적한 연구에서는 사망률이 줄어든 것으로 나타났으나 단면조사 방식으로 조사한 연구에서는 해당 지역 광역자치도 평균사망률과 비교하여 유의한 감소는 없는 것으로 보인다. 이는 추가 연구가 필요할 것으로 보인다. 고당등록관리사업의 경제성 평가 중 하나인 비용과 편익을 측정한 결과 비용 대비 편익비가 1:4인 것으로 나타났으며 이는 가장 보수적으로 접근한 것이다. 결국 정부예산에서 고당사업 지원이 이루어지지만 입원률 감소는 건강보험재정을 절감하는 것이며 사망률 감소는 비공식적 혹은 공식적 노동량 증가로 이어져 국민소득 증대에 영향을 미친다. 급속한 고령화 등으로 진료비 및 약제비 지원대상자 급증으로 고당등록관리업의 재정인 측면에서 지속가능성 도전에 직면하고 있다. 대안으로 째는 중앙정부 단위에서 고당등록관리사업의 정책우선순위를 높여 기획재정부가 진료비 및 약제비 지원을 늘어나는 노인등록자마큼늘리는 것이다. 둘째는 기초자치단체가 매년 사업한 도내에서 본인부담액(진료비) 지원 대상자를 연령 기준(75세 이상, 70세 이상, 65세 이상, 60세 이상, 30~64세 등)으로 맞추어 자율 선택하도록 하는 것이다. 셋째는 광역지방정부로부터의 재정 부담(대응교부금) 확보하는 것이다. 마지막으로 광역지방정부 또는 전국의 지역사회 특화사업으로서 확산시키는 것이다. (초)고령화 사회를 앞둔 농어촌지역으로 시급히 확산해야 할 필요가 있다. 고당등록관리사업의 건강 향상 효과는 과학적으로 입증되었으나 급속한 고령화로 인한 65세 이상 고혈압 및 당뇨환자 유병의 급증에 따른 진료비와 약제비 지원 앙등에 부담으로 전국확산 다소 지체되고 있다. 일차의료만성질환관리사업은 2024년 9월 30일부터 본사업으로 전환되었으나 등록환자들이 추가로 진료비를 지불해야 하다보니 시범사업 시 등록됐던 환자들은 본인부담 증가로 탈퇴양상을 보이고 신규등록 역시 쉽지 않은 것으로 보인다. 두 사업 모두 장단점이 뚜렷해보인다. 따라서 두 사업의 강점은 살리고 약점은 서로 보완하는 방향으로 연계와 협력이 이루어져 할 것이다. 연계와 협력은 세 가지 방향에서 이루어져야 한다. 첫째는 만성질환자의 대상자에 대한 역할분담이다. 고당등록관리사업은 65세 노인이나 경증질환자, 일차의료 만성질환관리사업은 65세미만이나 복합만성질환자 (제1형당뇨환자)를 대상으로 한다. 둘째는 제공자간 연계이다. 고당센터가 일차의료만성질환관리사업 의료기관의 코디네이터를 교육하는것이다. 셋째는 환자 의뢰 및 연계이다. 일차의료만성질환관리사업 의료기관의 만성질환자 관리에 참여하는 인력은 의사와 간호사이다. 따라서 영양교육이나 상담, 발관리 교육 등을 수행하기 어려울 것이다. 이러한 부족한 부분을 고당센터가 보완해주는 것이다. 또한 고당센터는 혈당 미조절자 대한 집중상담이 이루어지고 있으나 모집에 많은 어려움이 있는 일차의료만성질환관리사업이 어느정도 책임지고 고당센터 집중상담프로그램에 의뢰하는 것이다. 2. 청장년 환자 중심 교육·상담 방법론 개발 및 환자교육‧상담 실무자 실습교육 운영 청장년 고혈압·당뇨병 환자는 노년 환자와 다른 특성을 가지고 있어 기존의 교육상담방법을 적용하는데 한계가 있다. 이에 문헌고찰과 질적조사, 실무자 온라인조사, 현장인력 토론회를 통해 청장년환자 교육상담에 적절한 중재방법을 검토하고 청장년환자의 질환관리의 장애요인과 촉진요인을 파악하고 실제 현장 실무자의 의견을 청취하였다. 그 결과 행동변화중재, 동기강화상담 등이 청장년 환자 교육상담에 적용될 수 있는 것으로 확인되었다. 청장년 환자 교육상담은 사업장 근로자 중심의 사업모형이 제안되거나 적용 중이었으나 보건소 혹은 고당센터와 연계하는 데는 개인적, 사회환경적 장애요인이 있었다. 따라서 이를 고려한 사례 중심의 맞춤형 교육상담방법이 요구됨. 지역사회 환자교육·상담 실무자를 위한 실습교육 개발 및 운영은 문헌리뷰와 자문회의 실습교육 운영 및 실무자 온라인 설문조사를 통해 검토하였다. 그결과 국외에서는 고혈압·당뇨병 환자에게 교육상담 서비스를 제공하는 일이 특정 자격을 갖춘 사람만이 해야 하는 일임을 전제로 ‘환자교육상담’을 위한 전문성(speciality)을 갖추기 위한 체계적인 교육프로그램을 운영하고 있었다. 그러나 우리나라는 환자 교육상담서비스를 제공하는 인력의 직무 역량에 대한 규정이 없어 전문성을 갖춘 실무인력을 양성하기 위한 노력을 계속해 왔음에도 불구하고 아직 체계를 갖추지 못하였다. 이에 환자교육상담 인력의 질 확보를 위해서는 지식정보 전달 중심의 일회성 교육이 아니라 환자 사례 중심의 심화된 교육상담을 제공할 수 있는 전문성을 갖춘 인력을 양성 체계를 마련하는 것이 시급하다.

정책연구용역사업 최종결과보고서 편집순서 1 : 겉표지Community-based Registration and Management for elderly patients with Hypertension or Type 2 Diabetes mellitus Project (CRMHDP) by motivated primary care physicians and patients supported by prepared communities has positively impacted on health care utilization and health of the registed patients. However, the rapid aging population in South Korea in a recent decade caused CRMHDP putted at financial risk of the project. The budget for the project needed to be expanded by central and local governments. From Sep. 30 of 2024, local clinic baed chronic disease management program(LCCDMP) started in national wide. The cooperation and link between CRMHDP and LCCDMP should be required for the better health promotion amgon patients with type 2 Diabettes Mellitus and Hypertension. The Local center for CRMHDP should focus on enforcing the management of young patients with type 2 Diabetes Program. A effective education program need to be developed considering several barriers to disease managent which they have. Workforce in the Local Center for CRMHDP should be expertised in counselling and education of patient with chronic disease. The professional curriculum for them needs to be developed and run by the university and academic association. 연 구 사 업 명 2 0 질 병 관 리 청 정책연구용역사업 최종결과보고서 발간등록번호 국문 연구사업명 영문 연구사업명 주관연구기관 : 질 병 관 리 청 주 의 ( 주 의 내 용 기 재 ) (글 14 point 고딕체) ※ 주의 내용 주 의 1. 이 보고서는 질병관리청에서 시행한 정책연구용역사업의 최종결과보고서 입니다. 2. 이 보고서 내용을 발표할 때에는 반드시 질병관리청에서 시행한 정책 연구용역사업의 연구결과임을 밝혀야 합니다. 3. 국가 과학기술 기밀유지, 비밀 또는 비공개에 관한 내용은 대외적으로 발표 또는 공개하여서는 아니 됩니다. 편집순서 2 : 제출문 정책연구용역사업 최종결과보고서 연구사업번호 발주부서 질병관리청 과제담당관 방은옥 보안분류 ■ 일반 □ 보안 결과공개여부 ■ 공개 □ 비공개 연구사업명 국문명 생애 전주기적 만성질환 관리를 위한 질병모델 및 환자 중심 가이드 연구 영문명 A Study on the Disease Model and Patient-Centered Guide for Chronic Disease Control across the Entire Life Cycle 총 연구기간 2024. 7.30 ~ 2024.12.27 총 연구비 40,000천원 당해연도 연구기간 2024. 7.30 ~ 2024.12.27 당해연도 연구비 40,000천원 주관연구기관 중앙대학교 산학협력단 주관연구책임자 (직급) 이원영 (교수) 세부연구기관 구분 세부사업명 기관명 책임자성명 직급(직위) 1세부 지역사회기반 만성질환 예방관리 체계마련 중앙대학교 산학협력단 이원영 교수 2세부 환자중심교육/ 상담프로그램개발 중앙대학교 산학협력단 이원영 교수 연구참여자 총 11 명 (책임연구원: 1명, 연구원: 7명, 연구보조원: 3명 ) 20 년도 정책연구용역사업의 최종결과보고서를 붙임과 같이 제출합니다. 붙임 1. 최종결과보고서 제본 (oo부_발주부서 요청시) 2. 최종결과보고서 전자파일 (PDF변환 시 개인정보(전화번호, 이메일 등) 삭제) ※ 편집순서 1 : 겉표지에 ‘발간등록번호’ 반드시 기재 2024 년 12 월 27 일 주관연구책임자 : 이원영 (서명 또는 인) 주관연구기관장 : 중앙대학교 산학협력단 고중혁 (직인) 질 병 관 리 청 장 귀하 - 6 - 목 차 제1장 최종 연구목표 ··································································································································· 1 1. 연구배경 및 필요성 ···························································································································· 1 2. 연구목적 ················································································································································ 2 3. 연구수행체계 ········································································································································ 3 1) 추진 전략 및 방법 ···························································································································· 3 2) 연구추진체계 ······································································································································ 4 제2장 국내외 기술 현황 ····························································································································· 5 1. 지역사회 기반 만성질환 예방관리 수행체계 마련 ·········································································· 5 1) 고혈압·당뇨병 환자의 건강행태에 대한 공중보건학적 이해 ························································ 5 2) 고혈압·당뇨병등록관리사업의 도입과 운영 현황 ·········································································· 9 3) 일차의료만성질환관리사업 ················································································································· 13 2. 청장년 환자 중심 교육·상담 방법론 개발 및 환자교육‧상담 실무자 실습교육 운영 ··········· 16 제3장 최종 연구내용 및 방법 ················································································································ 17 1. 지역사회 기반 만성질환 예방관리 수행체계 마련 ······································································· 17 1) 고당등록관리사업의 효과평가 ··········································································································· 17 2) 고당등록관리사업의 경제성 평가 ····································································································· 17 3) 고당등록관리사업의 재정의 지속가능성 평가 및 대안 ······························································· 17 4) 고당등록관리사업과 일차의료만성질환관리사업 연계방안 ······················································· 19 2. 청장년 환자 중심 교육·상담 방법론 개발 및 환자교육‧상담 실무자 실습교육 운영 ········· 20 제4장 최종 연구결과 ································································································································ 22 - 7 - 1. 지역사회 기반 만성질환 예방관리 수행체계 마련 ······································································· 22 1) 효과 평가 ··············································································································································· 22 2) 경제성 평가 ··········································································································································· 46 3) 재정의 지속가능성 평가 및 대안 ····································································································· 51 4) 고당등록관리사업과 일차의료만성질환관리사업의 연계방안 ····················································· 79 2. 청장년 환자 중심 교육·상담 방법론 개발 및 환자교육‧상담 실무자 실습교육 운영 ··········· 96 1) 지역사회 청장년 환자 중심 교육상담 방법론 개발 ····································································· 96 2) 지역사회 환자교육‧상담 실무자 실습교육 개발 및 운영 ·························································· 125 제5장 연구결과 고찰 및 결론 ·············································································································· 151 1. 지역사회 기반 만성질환 예방관리 수행체계 마련 ····································································· 151 1) 고당등록관리사업의 건강효과 ······································································································ 151 2) 고당등록관리사업의 경제성 평가 ·································································································· 151 3) 재정의 지속가능성 평가와 대안 ···································································································· 152 4) 고당등록관리사업과 일차의료만성질환관리사업간 연계와 협력 ··········································· 153 2. 청장년 환자 중심 교육·상담 방법론 개발 및 환자교육‧상담 실무자 실습교육 운영 ······· 154 1) 지역사회 청장년 환자 중심 교육상담 방법론 개발 ··································································· 154 2) 지역사회 환자교육상담 실무자 실습교육 개발 및 운영 ··························································· 154 제6장 연구성과 및 활용계획 ················································································································ 155 제7장 정책연구용역사업 진행과정에서 수집한 해외과학기술정보 ·············································· 155 제8장 기타 중요변경사항 ······················································································································ 155 제9장 정책연구용역사업 유사도 검사결과 ························································································ 155 제10장 연구윤리 자가점검표 ················································································································ 164 제11장 연구비 사용 내역 및 연구 분담표 ························································································ 165 제12장 참고문헌 ······································································································································ 168 제13장 첨부서류 ······································································································································ 175 부 록 ·························································································································································· 176 □ 부록 1. ··············································································································································· 176 □ 부록 2. ··············································································································································· 180 □ 부록 3. ··············································································································································· 186 □ 부록 4. ················································································································································· 193 예산 산출내역서 ······························································································································ 193 - 9 - 표 목 차 표 Ⅱ-1 세계 국가별 다른 인구집단에서의 고혈압 환자에 대한 인식, 치료 및 조절의 빈도 ·16 표 Ⅱ-2. 일차의료만성질환관리사업의 통합관리료 항목과 수가 ··················································23 표 Ⅱ-3 포인트 적립·사용 기준 ··········································································································24 표 Ⅱ-4 개입군(고당등록관리사업군)과 대조군간 고혈압 및 당뇨병 주요 합병증에 따른 5년 간 입원발생 건수와 율 비 및 콕스회귀분석에 의한 보정발생위험비 ··········································36 표 Ⅱ-5 개입군(고당등록관리사업군)과 대조군간 고혈압 및 당뇨병 주요 합병증에 따른 5년 간 입원발생 건수와 율 비 및 콕스회귀분석에 의한 보정발생위험비 ··········································37 표 Ⅱ-6 센터별 참여자 수 ························································································································44 표 Ⅱ-7 평가 설계 ······································································································································45 표 Ⅱ-8 프로그램 참여자의 신체계측, 혈압, 혈당의 동일성 ···························································45 표 Ⅱ-9 신체계측 및 혈압·혈당 사전-사후 비교 ··············································································46 표 Ⅱ-10 신체계측 및 혈압·혈당 사전-추후 비교 ············································································46 표 Ⅱ-11 당뇨병 자가관리 및 식생활 진단 사전-사후, 사전-추후 비교 ······································47 표 Ⅱ-12 지식도와 자기효능감의 사전-사후 비교 ··············································································47 표 Ⅱ-13 당뇨병 자가관리 항목별 사전-사후, 사전-추후 변화 ······················································48 표 Ⅱ-14 집중관리군의 만족도(5점 만점) ·····························································································49 표 Ⅱ-15 개입군(고당등록관리사업군)과 대조군간 5년간 사망 건수와 율 콕스회귀분석에 의 한 보정발생위험비 ····································································································································50 표 Ⅱ-16. 비용-편익 추계 시 사용되는 누적등록자 수 ··································································56 표 Ⅱ-17 고혈압·당뇨병 등록관리 사업의 비용 추계 결과(5년간) ···············································57 ········································································································································································58 표 Ⅱ-19 고혈압·당뇨병 등록관리 사업의 편익 비용 비 (5년간) ·················································59 표 Ⅱ-20고혈압·당뇨병 등록관리 사업 경제성 평가에서의 민감도 분석 ····································59 표 Ⅱ-21 전국 고당사업 개별 지역별 연도별 위탁(고당센터) 및 직영 현황 ·······························64 표 Ⅱ-22 고당사업의 연도별 전체 예산(명목사업비 및 실질사업비) 추이 ···································68 표 Ⅱ-23 전국 고당사업 지역의 등록 대상자(노인환자)에 대한 진료비 지원 중단 현황 ·········72 표 Ⅱ-24 전국 고당사업 지역별 연도별 고당사업 예산의 기준(대응)보조율[국비:(광역:기초)지 방비 매칭] 현황 ··········································································································································76 표 Ⅱ-25 지역사회 기반 고혈압관리사업에 대한 국외 사례 ····························································84 표 Ⅱ-26 지역사회 기반 당뇨병관리사업에 대한 국외 사례 ····························································86 표 Ⅱ-27 당뇨병 환자 대상 동기강화상담 적용 연구 예 ································································104 표 Ⅱ-28 당뇨병 환자 대상 mHealth 적용 연구 예 ·········································································105 표 Ⅱ-29 당뇨병 환자 대상 환자중심관리 적용 연구 예 ································································107 표 Ⅱ-30 보건관리자 유무에 따른 서울시 근로자 만성질환관리체계 ··········································108 표 Ⅱ-31 전국 고혈압·당뇨병 등록교육센터의 사업장 대상 프로그램 내용 ····························116 표 Ⅱ-32 경기도 보건소-사업장 연계 현황 ························································································118 표 Ⅱ-33 청장년 고혈압·당뇨병 환자 대상 포커스그룹 인터뷰 일정 ········································121 표 Ⅱ-34 청장년 고혈압·당뇨병 환자 포커스그룹인터뷰 주요 결과 ··········································122 표 Ⅱ-35 응답자 특성 ······························································································································125 표 Ⅱ-36 청장년 고혈압·당뇨병 환자상담에 대한 자기효능감(N=70) ········································125 표 Ⅱ-37 청장년 환자상담에 대한 기술의 중요도와 수행도(N=70) ··············································126 표 Ⅱ-38 청장년 환자 현장인력 토론회 주요 내용 ········································································128 표 Ⅱ-39 청장년 환자 현장인력 토론회 시간표 ················································································128 표 Ⅱ-40 청장년 환자 현장인력 토론회 참석자 명단 ····································································129 표 Ⅱ-41 현장인력 토론회의 주요 내용 ······························································································130 표 Ⅱ-42 온라인 토론회 참석자 사진 ··································································································130 표 Ⅱ-43 대구 실습교육의 과정별 모듈 ······························································································131 표 Ⅱ-44 대구 실습교육 모듈의 주요 내용(1) ···················································································131 표 Ⅱ-45 대구 실습교육 모듈의 주요 내용(2) ···················································································132 표 Ⅱ-46 전문위원회 워크숍 주요 결과 ······························································································136 표 Ⅱ-47 신규자과정 각 강의의 교육목표와 교육방법 ····································································137 표 Ⅱ-48 경력자과정 각 강의의 교육목표와 교육방법 ····································································138 표 Ⅱ-49 실무자 온라인 설문조사 응답자의 일반적 특성(N=15) ··················································139 표 Ⅱ-50 대구와 경기도 실습교육의 장단점에 대한 의견 ······························································140 표 Ⅱ-51 전문가 자문회의 참석자 ········································································································142 표 Ⅱ-52 2024년 실습교육의 구성 ·······································································································143 표 Ⅱ-53 2024년 실습교육의 강사진 ···································································································144 표 Ⅱ-54 교육참여자의 일반적 특성 ····································································································145 표 Ⅱ-55 교육생의 자기효능감 교육전후 비교(N=18, 10점 만점) ·················································147 표 Ⅱ-56 교육생의 만족도 (N=18, 10점 만점) ···················································································148 그 림 목 차 그림 Ⅱ-1 지역사회 고혈압 환자에서의 절반의 법칙 ······································································16 그림 Ⅱ-2 절반의 법칙의 이론적 프레임워크 : 지역사회 당뇨병 환자 ········································18 그림 Ⅱ-3. 고혈압관리사업의 원형: 지역사회 기반 일차보건의료 시범사업 ·······························19 그림 Ⅱ-4 대구광역시 고혈압·당뇨병등록관리사업의 환자교육 네트워크모형 ··························21 그림 Ⅱ-5 전국 고혈압·당뇨병등록관리사업의 운영 현황 ··························································21 그림 Ⅱ-6. 고당등록관리사업의 주요내용 모식도 ··············································································23 그림 Ⅱ-7. 고혈압·당뇨병 환자 대상 일차의료 만성질환관리 서비스 제공 절차 ····················24 그림 Ⅱ-8 일차의료만성질환관리사업 등록 대상자 건강생활실천지원금제 절차 ························25 그림 Ⅱ-9 광명시와 대조군 지역(A와 B시)간 외래지속치료율 추이 (2007-2015) ·······················35 그림 Ⅱ-10 광명시와 대조군 지역(A와 B시)간 지역친화도 추이 (2007-2015) ·····························35 그림 Ⅱ-11 개입군(고당사업등록군)과 대조군(비등록, 고당사업 미 실시지역)의 추적기간 일 인당 연평균내원일수 (2009 – 2016) ·······································································································37 그림 Ⅱ-12 개입군(고당사업등록군)과 대조군(비등록, 고당사업 미 실시지역)의 추적기간 일 인당 연평균처방일수 (2009 – 2016) ·······································································································38 그림 Ⅱ-13 경기도-광명시 혈압인지율, 혈당인지율 (65세이상) ······················································39 그림 Ⅱ-14 경기도-하남시 혈압인지율, 혈당인지율 (65세이상) ······················································40 그림 Ⅱ-15 경기도-하남시 혈압인지율, 혈당인지율 (65세이상) ······················································41 그림 Ⅱ-16 경기도-광명시 당뇨병 안질환합병증검사, 신장질환합병증 검사 수진율 (65세이상) 42 그림 Ⅱ-17 경기도-하남시 당뇨병 안질환합병증검사, 신장질환합병증 검사 수진율 (65세이상) 43 그림 Ⅱ-18 경기도-남양주시 당뇨병 안질환합병증검사, 신장질환합병증 검사 수진율 (65세이 상) ··································································································································································44 그림 Ⅱ-19 경기도-광명시 허혈성 심장질환 사망률 ··········································································52 그림 Ⅱ-20 경기도-광명시 고혈압성 질환 사망률 ··············································································53 그림 Ⅱ-21 경기도-광명시 뇌혈관질환 사망률 ····················································································54 그림 Ⅱ-22 경기도-광명시 당뇨병 사망률 ····························································································55 그림 Ⅱ-23 비용-편익 분석 시 포함되는 비용과 편익의 항목 ························································56 그림 Ⅱ-24 고당사업 전체 지역의 연도별 연령구간별 인구 현황 및 추이 ··································62 그림 Ⅱ-25 고당사업의 권역별 연도별 연령구간별 인구 현황 및 추이 ······································63 그림 Ⅱ-26 전국 고당사업 개별 지역별 연도별 위탁(고당센터) 및 직영 현황 ···························65 그림 Ⅱ-27 고당사업 전체 지역과 권역별 연도별 누적 고당환자 등록 현황 및 추이 ············67 그림 Ⅱ-28 고당사업의 연도별 전체 예산: 명목 사업비와 실질 사업비의 비교 ······················68 그림 Ⅱ-29 고당사업의 연도별 전체 예산 및 보건소 운영비 추이 ··············································71 그림 Ⅱ-30 고당사업의 권역별 연도별 보건소 운영비 및 치료비 지원(비율) 추이 ·················75 그림 Ⅱ-31 고당사업 각 지역(위탁, 직영)별 연도별 담당인력 규모 및 인건비(비율) 추이 ·····79 그림 Ⅱ-32 HealthRise의 지역사회 기반 만성질환관리의 확산 ·····················································83 그림 Ⅱ-33 보건관리자 배치 사업장의 근로자 만성질환관리사업 체계(서울시) ·······················110 그림 Ⅱ-34 경기도 근로자 혈관건강프로그램 운영 체계 ································································111 그림 Ⅱ-35 근로자 업무수행 적합여부 내용(보건관리자 업무매뉴얼) ·········································113 그림 Ⅱ-36 뇌심혈관질환 발병위험도 평가 절차 ··············································································114 그림 Ⅱ-37. 사천시 질환대상자 만성질환 건강행태 개선 실천의 장애요인 ······························116 그림 Ⅱ-38 실습 교육프로그램 개발과정 ····························································································136 Ⅰ. 연구결과 요약문 (국문) 1. 지역사회 기반 만성질환 예방관리 수행체계 마련 고당등록관리사업의 효과를 의료체계, 의료이용, 건강행태, 사망률로 나누어 살펴 보았다. 의료체계에 미치는 효과에서는 일단 환자들이 처음 등록한 의료기관과 약국에만 가는 경향이 강해져 단골의사와 단골약사가 생겨 우리나라 의료전달체계에 순기능을 수행하는 것으로 보인 다. 이 점을 2012년 OECD 전문가들도 한국 의료체계의 질평가 보고서에서 언급하고 있다. 의 료이용 측면에서 고당등록관리사업을 하지 않는 지역에 비해 의료기관 방문 횟수가 1회 더 많 고 치료순응도가 증가하였으며 이로 인해 합병증으로 인한 입원율이 감소하고 사망률도 감소 한 것으로 나타났다. 건강행태 측면에서는 고당등록사업을 하는 지역에서 65세 노인들의 경우 타 지역 노인들에 비해 교육경험이수율, 혈압 및 혈당 인지율, 합병증 검사 수검율이 더 높은 것으로 나타났으며 일부 지역에서는 뇌졸중과 허혈성심장질환의 조기증상 인지도가 높은 것으 로 나타났다. 셋째, 사망률의 경우 특정 연도에 등록자군을 5년간 추적한 연구에서는 사망률이 줄어든 것으로 나타났으나 단면조사 방식으로 조사한 연구에서는 해당 지역 광역자치도 평균 사망률과 비교하여 유의한 감소는 없는 것으로 보인다. 이는 추가 연구가 필요할 것으로 보인 다. 고당등록관리사업의 경제성 평가 중 하나인 비용과 편익을 측정한 결과 비용 대비 편익비 가 1:4인 것으로 나타났으며 이는 가장 보수적으로 접근한 것이다. 결국 정부예산에서 고당사 업 지원이 이루어지지만 입원률 감소는 건강보험재정을 절감하는 것이며 사망률 감소는 비공 식적 혹은 공식적 노동량 증가로 이어져 국민소득 증대에 영향을 미친다. 급속한 고령화 등으로 진료비 및 약제비 지원대상자 급증으로 고당등록관리업의 재정인 측면에서 지속가능성 도전에 직면하고 있다. 대안으로 째는 중앙정부 단위에서 고당등록관리사 업의 정책우선순위를 높여 기획재정부가 진료비 및 약제비 지원을 늘어나는 노인등록자마큼 늘리는 것이다. 둘째는 기초자치단체가 매년 사업한 도내에서 본인부담액(진료비) 지원 대상자 를 연령 기준(75세 이상, 70세 이상, 65세 이상, 60세 이상, 30~64세 등)으로 맞추어 자율 선택 하도록 하는 것이다. 셋째는 광역지방정부로부터의 재정 부담(대응교부금) 확보하는 것이다. 마 지막으로 광역지방정부 또는 전국의 지역사회 특화사업으로서 확산시키는 것이다. (초)고령화 사회를 앞둔 농어촌지역으로 시급히 확산해야 할 필요가 있다. 고당등록관리사업의 건강 향상 효과는 과학적으로 입증되었으나 급속한 고령화로 인한 65 세 이상 고혈압 및 당뇨환자 유병의 급증에 따른 진료비와 약제비 지원 앙등에 부담으로 전국 확산 다소 지체되고 있다. 일차의료만성질환관리사업은 2024년 9월 30일부터 본사업으로 전환 되었으나 등록환자들이 추가로 진료비를 지불해야 하다보니 시범사업 시 등록됐던 환자들은 본인부담 증가로 탈퇴양상을 보이고 신규등록 역시 쉽지 않은 것으로 보인다. 두 사업 모두 장 단점이 뚜렷해보인다. 따라서 두 사업의 강점은 살리고 약점은 서로 보완하는 방향으로 연계와 협력이 이루어져 할 것이다. 연계와 협력은 세 가지 방향에서 이루어져야 한다. 첫째는 만성질 환자의 대상자에 대한 역할분담이다. 고당등록관리사업은 65세 노인이나 경증질환자, 일차의료 만성질환관리사업은 65세미만이나 복합만성질환자 (제1형당뇨환자)를 대상으로 한다. 둘째는 제공자간 연계이다. 고당센터가 일차의료만성질환관리사업 의료기관의 코디네이터를 교육하는 것이다. 셋째는 환자 의뢰 및 연계이다. 일차의료만성질환관리사업 의료기관의 만성질환자 관 리에 참여하는 인력은 의사와 간호사이다. 따라서 영양교육이나 상담, 발관리 교육 등을 수행 하기 어려울 것이다. 이러한 부족한 부분을 고당센터가 보완해주는 것이다. 또한 고당센터는 혈당 미조절자 대한 집중상담이 이루어지고 있으나 모집에 많은 어려움이 있는 일차의료만성 질환관리사업이 어느정도 책임지고 고당센터 집중상담프로그램에 의뢰하는 것이다. 2. 청장년 환자 중심 교육·상담 방법론 개발 및 환자교육‧상담 실무자 실 습교육 운영 청장년 고혈압·당뇨병 환자는 노년 환자와 다른 특성을 가지고 있어 기존의 교육상담방 법을 적용하는데 한계가 있다. 이에 문헌고찰과 질적조사, 실무자 온라인조사, 현장인력 토론회 를 통해 청장년환자 교육상담에 적절한 중재방법을 검토하고 청장년환자의 질환관리의 장애요 인과 촉진요인을 파악하고 실제 현장 실무자의 의견을 청취하였다. 그 결과 행동변화중재, 동 기강화상담 등이 청장년 환자 교육상담에 적용될 수 있는 것으로 확인되었다. 청장년 환자 교 육상담은 사업장 근로자 중심의 사업모형이 제안되거나 적용 중이었으나 보건소 혹은 고당센 터와 연계하는 데는 개인적, 사회환경적 장애요인이 있었다. 따라서 이를 고려한 사례 중심의 맞춤형 교육상담방법이 요구됨. 지역사회 환자교육·상담 실무자를 위한 실습교육 개발 및 운 영은 문헌리뷰와 자문회의 실습교육 운영 및 실무자 온라인 설문조사를 통해 검토하였다. 그 결과 국외에서는 고혈압·당뇨병 환자에게 교육상담 서비스를 제공하는 일이 특정 자격을 갖 춘 사람만이 해야 하는 일임을 전제로 ‘환자교육상담’을 위한 전문성(speciality)을 갖추기 위 한 체계적인 교육프로그램을 운영하고 있었다. 그러나 우리나라는 환자 교육상담서비스를 제공 하는 인력의 직무 역량에 대한 규정이 없어 전문성을 갖춘 실무인력을 양성하기 위한 노력을 계속해 왔음에도 불구하고 아직 체계를 갖추지 못하였다. 이에 환자교육상담 인력의 질 확보를 위해서는 지식정보 전달 중심의 일회성 교육이 아니라 환자 사례 중심의 심화된 교육상담을 제공할 수 있는 전문성을 갖춘 인력을 양성 체계를 마련하는 것이 시급하다.