外来管理加算が避けられる入院に与える影響

後ろ向きコホート研究

Abstract

目的：非感染症疾患の重症化予防や管理においてプライマリ・ケアは重要な役割を担っている．Ambulatory care sensitive condition (ACSC)とは適切な外来診療を受ける事で入院を避ける事のできる状態と定義される．プライマリ・ケアに関連した診療報酬上の評価の一つに外来管理加算があるが，外来管理加算を算定した計画的な医学管理が患者の健康に与える影響についてあきらかになっていない．本研究の目的はプライマリ・ケアが行われる診療所において，高齢者に対する外来管理加算を算定する医学管理がACSCによる入院を減らすかどうかを検討することである． 方法：診療所において心不全，高血圧，糖尿病，高脂血症のいずれかに対して，初回の再診から連続して3ヶ月連続で月1回特定疾患療養管理料が算定されている65歳以上の患者を対象とした．外来管理加算を算定した群としていない群で傾向スコアによる1:4マッチングを行い，ACSCによる入院を比較した．主要アウトカムはACSCのうち適切な外来での管理によって避けられる入院（慢性ACSCによる入院）とした． 結果：傾向スコアマッチング後，外来管理加算を算定した群が5,188人，算定していない群が1,297人となった．両群間で，慢性ACSCによる入院に統計的に有意差を認めなかった（1.4％ vs. 1.7％, p=0.472）． 結論：診療所で心不全，高血圧，糖尿病，高脂血症を治療しているものの安定的な状態にある高齢者に対する外来管理加算による医学管理は，慢性ACSCによる入院と統計的に有意な関連を認めなかった．

Translated Abstract

Objectives: Primary care plays a crucial role in preventing the exacerbation of non-communicable diseases and managing them effectively. Ambulatory care sensitive conditions (ACSCs) are defined as conditions where hospitalizations can be avoided through appropriate ambulatory care. Although health insurance reimbursement schemes in primary care include a “fee for a comprehensive review on care for outpatients,” the impact of this financial incentive on healthcare outcomes remains unclear. The present study aimed to determine whether this fee schedule was associated with reduction in hospitalizations due to ACSCs primarily treated in clinics. Methods: This study included patients who were i) aged 65 years or older, ii) diagnosed with and treated for heart failure, hypertension, diabetes, or hyperlipidemia, and iii) reimbursed for “fee for medication for the specific lifestyle-related diseases” for three consecutive months from the first follow-up examination in a clinic. We conducted a one-to-four propensity score matching between patients with and without the “fee for a comprehensive review on care for outpatients.” The primary outcome was hospitalizations related to chronic ACSCs that could be prevented with appropriate ambulatory care. Results: The propensity score matched cohort included 5,188 patients with the fee and 1,297 patients without the fee. No significant difference was observed in hospitalizations related to chronic ACSCs (1.4% vs. 1.7%, p=0.472) between the two groups. Conclusion: The incentive scheme was not associated with hospitalizations related to chronic ACSCs among older outpatients with stable conditions who received treatment for either heart failure, hypertension, diabetes, or hyperlipidemia in clinics.

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