診療報酬改定後の嚥下障害患者の動向について

A study of the trend of dysphagia patients before and after the revision of medical service fee system

　平成18年度にリハビリテーション診療報酬の大幅な改定が施行され，急性期病院入院期間や回復期リハビリテーション病棟の入棟期限の短縮化，算定上限の変更などが行われた．診療報酬改定前の17年度と改定後の18年度の当院における嚥下障害患者の動向について調査した結果，全体では在院日数の短縮化，嚥下治療成績の向上，在宅復帰率の向上など診療報酬改定による実績を認めた一方で，注意・遂行機能障害合併群は，ほかの障害群と比較して在院日数の有意な短縮や嚥下治療成績の制限，転院率の増加を認めた．注意・遂行機能障害群がほかの障害群と比較して逆の方向を示した背景に，障害が嚥下障害に与える特性が考えられた．特に，注意障害は摂食・嚥下能力の獲得を阻害する要因として知られており，ほかの障害群と比較して代償法の獲得を含め環境調整に時間が必要であると考えられた．

　Major revisions of the medical service fee system including rehabilitation have come into force since 2006.　They shortened both the length of hospitalization during the acute stage and the convalescent rehabilitation period by setting an upper limit date.　We investigated the trend of dysphagia patients in Kurashiki Rehabilitation hospital between 2005 and 2006 before and after the revision.　Overall results showed a reduction in the length of hospitalization and an increase in the number of patients returning home.　However, when the patients with attention and executive disorders were compared with aphasic patients, we found significantly shortened hospitalization periods, reduced curative effects, and an increase in the proportion of patients discharged to another hospital.　The results for attention and executive disorders patients can be explained when we consider the negative effects of attention disorder on recovery of dysphagia.　Patients with attention disorder need more time for making environmental adjustments including acquisition of compensational skills.