EB1-2011-82 Comprehensive Quality Report of National Health Insurance 2010 Comprehensive Quality Report of National Health Insurance 2010 The Health Insurance Review & Assessment Service (HIRA) is dedicated to enhancing the public’s health and the quality of the nation’s medical services, while reviewing the propriety of medical costs. All HIRA members are doing their utmost to ensure that the public receive the highest possible quality of medical service. HIRA has been conducting the work of the quality assessment since July 2000. During the early stages, the assessment was focused on the level of use of medical services. It then began improving its quality by expanding its boundaries to the assessment of clinical quality. In addition, for the purpose of encouraging the use of assessment results, HIRA relays the results to medical service providers and the public, and expands the linkage with a value incentive project and the quality improvement program. “Comprehensive Quality Report of National Health Insurance 2010” is the second report, following the initial one in 2009. The report will be consecutively published each year addressing the changes and accomplishments of the quality assessment. It is with our sincere appreciation and gratitude that we thank all who have made such tremendous efforts in data collection and quality improvement activities. We also hope that this report will serve as useful material for understanding the quality assessment activities and the level of our medical practices, and for upgrading the quality of healthcare services. July 2011 Kang Yoon Koo President of HIRA Comprehensive Quality Report of National Health Insurance 2009 Summary / iii Part. Quality Assessment System 1 1. Background to Quality Assessment 3 01 2. Concepts and Objectives of Assessment 8 ● ● ● ● 3. Quality Assessment Procedure and Methods 12 Part. Quality Assessment in 2010 19 1. Summary of 2010 Assessment 21 02 2. Quality Assessment Results by Area 36 ● ● ● ● 2.1 Inpatient care area 36 2.1.1 Acute myocardial infarction 36 2.1.2 Acute stroke 46 2.1.3 Use of prophylactic antibiotics for surgery 55 2.1.4 Caesarean delivery 69 2.1.5 Surgical volume indicator 77 2.2 Long-term care area 83 2.2.1 Long-term care hospital 83 2.2.2 Mental hospital within medical aid 93 2.2.3 Hemodialysis 100 2.3 Outpatient services 108 2.3.1 Prescription 108 Part. Quality Improvement Program 119 1. Public Reporting of the Assessment Results 122 03 2. “HIRA Value Incentive Program” Demonstration Project 129 ● ● ● ● 3. Quality Improvement (QI) Support Program 144 Part. Appendix 153 Appendix I. Indicator List for Assessment Items 155 04 Appendix 2. Results by Assessment Items and Healthcare Institutions 194 ● ● ● ● Contents Summary Table 1. 2010 Assessment areas and target institutions. 7 Summary Table 2. 2010 Data sources, target period and data collection by assessment items 8 Summary Table 3. 2010 Quality assessment results by item 11 Summary Table 4. Current status of payments for the incentives and disincentives 17 Table 2.1 2010 Assessment areas and assessment institutions 26 Table 2.2 2010 Data sources, target period and data collection by assessment items 27 Table 2.3 2010 Quality assessment results by item 30 Table 2.4 Assessment results of acute myocardial infarction by indicator 40 Table 2.5 Assessment results of AMI by institution 42 Table 2.6 Composite scores of AMI assessment 43 Table 2.7 Overall assessment results of AMI by type of institution 44 Table 2.8 Claiming status of AMI cases assessed 45 Table 2.9 Other key factors related to AMI assessment 45 Table 2.10 The Status of specialized personnel employed by the institutions assessed for acute stroke. 49 Table 2.11 Assessment results 1 of acute stroke by type of institution 50 Table 2.12 Assessment results 2 of acute stroke by type of institution 53 Table 2.13 Institutional status by grade based on the CQS of acute stroke 55 Table 2.14 Total assessment results by indicator of prophylactic for surgery 60 Table 2.15 Average rate of prophylactic antibiotics use for surgery and variation between 2007 and 2008 62 Table 2.16 Assessment results of prophylactic antibiotics for surgery by type of institution 64 Table 2.17 Overall assessment results of prophylactic antibiotics for surgery by type of institution 65 Table 2.18 CQS of prophylactic antibiotics for surgery (by type of surgery) 66 Table 2.19 Assessment results of prophylactic antibiotics for surgery by type of surgery 67 Table 2.20 Total results of Caesarean delivery rates 72 Table 2.21 Overall assessment results of Caesarean delivery rates by type of institution 74 Table 2.22 Assessment of C-section delivery services 75 Table 2.23 Caesarean delivery rate in primipara by Type of Institution 75 Table 2.24 Transition of VBAC rate 76 Table 2.25 Service volume, cut-off point and fatality rate by surgery 80 Table 2.26 Overall assessment results of surgical volume by cancer type and type of institution 81 Table 2.27 Claiming status of surgical volume assessment 82 Table 2.28 Assessment results of long-term care hospital structure indicator 87 - iv - Table 2.29 Assessment results of long-term care hospital structure indicator 88 Table 2.30 Assessment results of medical service (process, outcome) indicators for long-term care hospitals 90 Table 2.31 Overall assessment results of long-term care hospitals 91 Table 2.32 Assessment results of the structural indicators from mental hospital within medical aid 96 Table 2.33 Assessment results of structure indicators of mental hospital within medical aid 97 Table 2.34 Assessment results of outcome indicators of mental hospital within medical aid 98 Table 2.35 CQS Status of mental hospital within medical aid 98 Table 2.36 Assessment results for structure indicators of hemodialysis 103 Table 2.37 Assessment results 1 for process indicators of hemodialysis 104 Table 2.38 Assessment results 2 for process indicators of hemodialysis 105 Table 2.39 Overall assessment results of hemodialysis by type of institution 106 Table 2.40 Claims status of hemodialysis assessment 106 Table 2.41 Assessment results of hemodialysis monitoring indicators 107 Table 2.42 Number of subject institutions of prescription assessment (4th quarter based) 109 Table 2.43 Assessment Results of Prescription by Indicator (Health Insurance) 112 Table 2.44 Overall assessment results of prescription rate of injections by type of institution for (2nd half, 2010) 114 Table 2.45 Overall Assessment Results of Antibiotics Prescription Rate for Acute Upper Respiratory by Type of Institution (2nd half, 2010) 115 Table 2.46 Overall assessment results of number of drugs per prescription by type of institution (2nd half, 2010) 115 Table 3.1 The payment status of incentives and disincentives 134 Table 3.2 Annual CQS 135 Table 3.3 The composite scores of ami AMI assessment by year & grade 136 Table 3.4 Location of medical care institutions by grade 137 Table 3.5 Results of process indicators by year 137 Table 3.6 Results of fatality rate by year 139 Table 3.7 Standard scores by year 140 Table 3.8 Variations of CQS in Caesarean section by year and grade 141 Table 3.9 Regional distribution of hospital locations by grade (2009) 141 Table 3.10 Yearly contents of the QI Newsletter 145 Table 3.11 Yearly contents of Yak! Baru Baru newsletter 148 - v - Contents Summary Figure 1. Relationship between care quality and quality assessment 3 Summary Figure 2. 2010 Quality assessment direction 5 Summary Figure 3. Direction of expanding assessment areas 20 Figure 1.1 Changes in quality assessment 5 Figure 1.2 Annual status of quality assessment (2006-2010) 7 Figure 1.3 The relationship between care quality and quality assessment 9 Figure 1.4 Purpose of quality assessment 11 Figure 1.5 Assessment implementation procedures 13 Figure 1.6 Data collection method using administrative data 15 Figure 1.7 Data collection method using administrative data and survey sheet 16 Figure 1.8 Utilization of quality assessment results 18 Figure 2.1 Changes of aging population and medical benefit costs paid for elderly citizens 21 Figure 2.2 The direction of healthcare quality assessment 2010 22 Figure 2.3. Direction of expanding the assessment areas 35 Figure 2.4 The Occurrence of ischemic heart diseases per 100,000 of population 36 Figure 2.5 Assessment results of AMI by indicator 41 Figure 2.6 Assessment results of AMI by type of institution 43 Figure 2.7 Overall results of AMI assessment 44 Figure 2.8 The number of acute stroke patients and status of medical cost 46 Figure 2.9 Annual assessment results of acute stroke by process indicator 51 Figure 2.10 Annual assessment results of acute stroke by process indicator 52 Figure 2.11 Assessment results of acute stroke process indicator by type of institution 54 Figure 2.12 Status of the number of claims and medical cost on the subject surgeries of assessment 56 Figure 2.13 Total assessment results by indicator of prophylactic antibiotics for surgery (by year) 61 Figure 2.14 Results by indicator of prophylactic antibiotics for surgery 63 Figure 2.15 Distributions of indicators of prophylactic antibiotics for surgery (by type of institution) 65 Figure 2.16 CQS of prophylactic antibiotics for surgery (by type of surgery) 66 Figure 2.17 The volume of prophylactic use of antibiotics for surgery and the number of surgery cases 67 Figure 2.18 DDD Changes in prophylactic antibiotics use for surgery 68 Figure 2.19 Annual changes of target delivery 69 Figure 2.20 Transition of C-section delivery rate 72 Figure 2.21 Transition of Caesarean