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Jeong SH, Hurh K, Park EC, Leigh JH, Kim SH, Jang SI. Risk of Pancreatic Cancer After Acute Pancreatitis: A Retrospective Analysis of the Korean National Sample Cohort. J Korean Med Sci 2024; 39:e21. [PMID: 38288535 PMCID: PMC10825454 DOI: 10.3346/jkms.2024.39.e21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 11/22/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Acute pancreatitis may increase the risk of pancreatic cancer, although this association remains unclear. Therefore, we aimed to investigate this association. METHODS We retrospectively analyzed the 2002-2019 Korean National Health Insurance Service-National Sample Cohort using 1:3 propensity score matching for sex and age (acute pancreatitis, n = 4,494; matched controls, n = 13,482). We calculated the hazard ratio (HR) for pancreatic cancer risk in patients with acute pancreatitis using Cox proportional hazards regression. RESULTS Acute pancreatitis was significantly associated with an increased risk of pancreatic cancer throughout the study period (adjusted HR, 7.56 [95% confidence interval, 5.00-11.41]), which persisted for 2, 2-5, and > 5 years post-diagnosis (19.11 [9.60-38.05], 3.46 [1.35-8.33], and 2.73 [1.21-6.15], respectively). This pancreatitis-related pancreatic cancer risk became insignificant beyond 10 years of follow-up (1.24 [0.24-6.49]). Furthermore, this risk notably increased as the number of recurrent acute pancreatitis episodes increased (1 episode: 5.25 [3.31-8.33], 2 episodes: 11.35 [6.38-20.19], ≥ 3 episodes: 24.58 [13.66-44.26]). CONCLUSION Following an acute pancreatitis diagnosis, the risk of pancreatic cancer increases significantly in the initial years, with a rapid increase further accentuated with recurrent acute pancreatitis episodes. Additional study is needed to evaluate whether this increased risk of carcinogenesis is attributed to accumulated inflammation.
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Affiliation(s)
- Sung Hoon Jeong
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Health Services Research, Yonsei University, Seoul, Korea
- Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea
| | - Kyungduk Hurh
- Institute of Health Services Research, Yonsei University, Seoul, Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ja-Ho Leigh
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea
| | - Seung Hoon Kim
- Institute of Health Services Research, Yonsei University, Seoul, Korea
- Department of Preventive Medicine, Eulji University School of Medicine, Daejeon, Korea.
| | - Sung-In Jang
- Institute of Health Services Research, Yonsei University, Seoul, Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Yun I, Hurh K, Jeong SH, Park EC, Jang SI. The risk of osteoporotic fractures after gastrectomy: Findings from the Korean national sample cohort database (2002-2019). Front Oncol 2022; 12:1014817. [PMID: 36505862 PMCID: PMC9732427 DOI: 10.3389/fonc.2022.1014817] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/31/2022] [Indexed: 11/26/2022] Open
Abstract
Objective This study used a national sample cohort database to investigate the risk of osteoporotic fractures after gastrectomy is performed for gastric cancer. Materials and Methods We used data from the Korea National Health Insurance Service-National Sample Cohort between 2002 and 2019. After performing 1:3 propensity score matching, 28,328 individuals were analysed in the final study (7, 082 cases; 21, 246 controls). Gastrectomy data were extracted from the coded claims data, and osteoporotic fractures were defined as the occurrence of fractures in any of the vertebrae, distal radius, humerus, or hip, according to the 10th version of the International Classification of Diseases. A Cox proportional hazards regression model was generated to investigate the association between gastrectomy and risk of osteoporotic fractures. Results Patients with gastric cancer who underwent a gastrectomy had a higher risk of osteoporotic fractures as compared to the general population (men, hazard ratio [HR]: 1.13, 95% confidence interval [CI]: 1.00-1.27; women, HR: 1.18, 95% CI: 1.06-1.30). A significantly higher risk of osteoporotic fractures was observed with surgical resection than with endoscopic resection (men, surgical, HR: 1.28, 95% CI: 1.08-1.52, endoscopic, HR: 1.04, 95% CI: 0.90-1.21; women, surgical, HR: 1.34, 95% CI: 1.11-1.62, endoscopic, HR: 1.13, 95% CI: 1.01-1.27). In men, the risk of hip fracture was the highest among the four fracture sites (HR: 1.18, 95% CI:0.89-1.56), while in women, the risk of vertebral fracture after gastrectomy was the highest (HR: 1.16, 95% CI: 0.99-1.35). Conclusion Patients with gastric cancer who underwent gastrectomy had a higher risk of osteoporotic fractures as compared to the general population. This suggests the need for bone metabolism management in patients with gastric cancer to prevent post-gastrectomy complications.
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Affiliation(s)
- Il Yun
- Department of Public Health, Graduate School, Yonsei University, Seoul, South Korea,Institute of Health Services Research, Yonsei University, Seoul, South Korea
| | - Kyungduk Hurh
- Institute of Health Services Research, Yonsei University, Seoul, South Korea,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Hoon Jeong
- Department of Public Health, Graduate School, Yonsei University, Seoul, South Korea,Institute of Health Services Research, Yonsei University, Seoul, South Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, South Korea,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung-In Jang
- Institute of Health Services Research, Yonsei University, Seoul, South Korea,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea,*Correspondence: Sung-In Jang,
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Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up. PLoS One 2021; 16:e0260460. [PMID: 34852015 PMCID: PMC8635587 DOI: 10.1371/journal.pone.0260460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/09/2021] [Indexed: 11/19/2022] Open
Abstract
Objective The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. Methods The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. Results The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years. Conclusion Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.
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Jung JM, Chung CK, Kim CH, Choi Y, Kim MJ, Yim D, Yang SH, Lee CH, Hwang SH, Kim DH, Yoon JH, Park SB. The Long-term Reoperation Rate Following Surgery for Lumbar Stenosis: A Nationwide Sample Cohort Study With a 10-year Follow-up. Spine (Phila Pa 1976) 2020; 45:1277-1284. [PMID: 32355142 DOI: 10.1097/brs.0000000000003515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of a nationwide sample database. OBJECTIVE The objective of the present study was to compare the long-term incidence of reoperation for lumbar spinal stenosis (LSS) after anterior fusion, posterior fusion, and decompression. SUMMARY OF BACKGROUND DATA Surgical treatment for LSS can be largely divided into 2 categories: decompression only and decompression with fusion. A previous nationwide study reported that fusion surgery was performed in 10% of patients with LSS, and the 10-year reoperation rate was approximately 17%. However, with the development of surgical techniques and changes in surgical trends, these results should be reassessed. METHODS The National Health Insurance Service-National Sample Cohort of the Republic of Korea was utilized to establish a cohort of adult patients (N = 1400) who first underwent surgery for LSS during 2005 to 2007. Patients were followed for 8 to 10 years. Considering death before reoperation as a competing event, reoperation hazards were compared among surgical techniques using a Fine and Gray regression model after adjustment for sex, age, diabetes, osteoporosis, Charlson comorbidity index, severity of disability, type of medical coverage, and type of hospital. RESULTS The overall cumulative incidence of reoperation was 6.2% at 2 years, 10.8% at 5 years, and 18.4% at 10 years. The cumulative incidence of reoperation was 20.6%, 12.6%, and 18.6% after anterior fusion, posterior fusion, and decompression, respectively, at 10 years postoperatively (P = 0.44). The first surgical technique did not affect the reoperation type (P = 0.27). Decompression was selected as the surgical technique for reoperation in 83.5% of patients after decompression, in 72.7% of patients after anterior fusion, and in 64.3% of patients after posterior fusion. CONCLUSION The initial surgical technique did not affect reoperation during the 10-year follow-up period. Decompression was the most commonly used technique for reoperation. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min-Jung Kim
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dahae Yim
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang Hyun Lee
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Hwan Hwang
- Department of Neurosurgery, Korean Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Dong Hwan Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joon Ho Yoon
- Department of Neurosurgery, Korean Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Sung Bae Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Boramae Hospital, Seoul, Republic of Korea
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The Reply. Am J Med 2020; 133:e443. [PMID: 32741450 DOI: 10.1016/j.amjmed.2020.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/05/2020] [Indexed: 11/21/2022]
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Long-Term Effect of Diabetes on Reoperation After Lumbar Spinal Surgery: A Nationwide Population-Based Sample Cohort Study. World Neurosurg 2020; 139:e439-e448. [PMID: 32305613 DOI: 10.1016/j.wneu.2020.04.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetes mellitus (DM) is associated with poor postoperative outcomes and increased morbidity after surgeries. Some previous studies have addressed the close association between DM and those leading to reoperations, whereas others have rejected this theory. This study aimed to evaluate the long-term effect of DM on lumbar spinal surgery using data from a nationwide sample cohort. METHODS A population-based cohort comprised one million people, which is a 2.1% representative sample of the Korean population. The present study included adult patients with lumbar degenerative diseases (e.g., lumbar spinal stenosis and spondylolisthesis), who underwent their first lumbar surgery in 2006. The cumulative incidence function for reoperation was calculated and multivariate analysis was performed to define correlation between reoperation and independent factors. RESULTS A total of 2020 patients were enrolled and followed up for 10 years. Nondiabetic patients, patients with DM without complication (DwoC), and patients with DM with complication (DwC) accounted for 79.5%, 9.36%, and 11.14% of all patients, respectively. Reoperation incidence stratified by DM was 12.7% for nondiabetic patients, 22.2% for patients with DwoC, and 20.0% for patients with DwC in 10 years of follow-up. During the same period, death, a competing event of reoperation, occurred in 7.8% of nondiabetic patients, in 13.2% of patients with DwoC, and in 20.9% of patients with DwC. CONCLUSIONS DM increased 1.65 times the overall cumulative incidences of reoperation after lumbar spinal surgeries for 10 years of follow-up. The reoperation incidence for DwC may be lower than that for DwoC because of a high incidence of death as a competing event of reoperation.
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The Long-term Reoperation Rate Following Surgery for Lumbar Herniated Intervertebral Disc Disease: A Nationwide Sample Cohort Study With a 10-year Follow-up. Spine (Phila Pa 1976) 2019; 44:1382-1389. [PMID: 30973508 DOI: 10.1097/brs.0000000000003065] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study of a nationwide sample database. OBJECTIVE The objective of the present study was to compare the long-term incidence of reoperation for lumbar herniated intervertebral disc disease (HIVD) after major surgical techniques (open discectomy, OD; laminectomy; percutaneous endoscopic lumbar discectomy, PELD; fusion). SUMMARY OF BACKGROUND DATA HIVD is a major spinal affliction; if the disease is intractable, surgery is recommended. Considering both the aging of patients and the chronicity of lumbar degenerative disease, the effect of surgical treatment for the lumbar spine should be durable for as long as possible. METHODS The National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Republic of Korea was utilized to establish a cohort of adult patients (N = 1856) who underwent first surgery for lumbar HIVD during 2005 to 2007. Patients were followed for 8 to 10 years. Considering death before reoperation as a competing event, reoperation hazards were compared among surgical techniques using the Fine and Gray regression model after adjustment for age, gender, Charlson comorbidity score, osteoporosis, diabetes, the severity of disability, insurance type, and hospital type. RESULTS The overall cumulative incidences of reoperation were 4% at 1 year, 6% at 2 years, 8% at 3 years, 11% at 5 years, and 16% at 10 years. The cumulative incidences of reoperation were 16%, 14%, 16%, and 10% after OD, laminectomy, PELD, and fusion, respectively, at 10 years postoperation, with no difference among the surgical techniques. However, the distribution of reoperation types was significantly different according to the first surgical technique (P < 0.01). OD was selected as the reoperation surgical technique in 80% of patients after OD and in 81% of patients after PELD. CONCLUSION The probability of reoperation did not differ among OD, laminectomy, PELD, and fusion during the 10-year follow-up period. However, OD was the most commonly used technique in reoperation. LEVEL OF EVIDENCE 4.
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Jung JM, Lee SU, Hyun SJ, Kim KJ, Jahng TA, Oh CW, Kim HJ. Trends in Incidence and Treatment of Herniated Lumbar Disc in Republic of Korea : A Nationwide Database Study. J Korean Neurosurg Soc 2019; 63:108-118. [PMID: 31408926 PMCID: PMC6952735 DOI: 10.3340/jkns.2019.0075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/31/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aimed to determine the incidence and analyze trends of the herniated lumbar disc (HLD) based on a national database in the Republic of Korea (ROK) from January 2008 to December 2016. METHODS This study was a retrospective analysis of data obtained from the national health-claim database provided by the National Health Insurance Service for 2008-2016 using the International Classification of Diseases. The crude incidence and age-standardized incidence of HLD were calculated, and additional analysis was conducted according to age and sex. Changes in trends in treatment methods and some treatments were analyzed using the Korean Classification of Diseases procedure codes. RESULTS The number of patients diagnosed with HLD was 472245 in 2008 and increased to 537577 in 2012; however, it decreased to 478697 in 2016. The pattern of crude incidence and the standardized incidence were also similar. Overall, the incidence of HLD increased annually for the 30s, 40s, 50s, and 70s until 2012 and then decreased. However, the incidence of HLD for the 80s continued to increase. The crude incidence of HLD in female patients exceeded that of male patients in their middle age (30s or 40s) and was 1.5-1.6 times higher than in male patients in their 60s. The total number of open discectomy (OD) increased from 71598 in 2008 to 93942 in 2012 and then decreased to 85846 in 2016. The rate of younger patients (the 20s, 30s, and 40s) who underwent OD was decreased, and the rate of younger patients who underwent percutaneous endoscopic lumbar discectomy was increased. However, the rate of older patients (the 70s and 80s) who underwent OD was continuously increased. CONCLUSION This nationwide data on HLD from 2008 to 2016 in the ROK demonstrated that the crude incidence and the standardized incidence increased until 2012 and then decreased. The annual crude incidence was different according to age and sex. These findings may be considered when deciding future health policy, especially in countries with a similar national health insurance system (or with plans to adopt).
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Maharani C, Djasri H, Meliala A, Dramé ML, Marx M, Loukanova S. A scoping analysis of the aspects of primary healthcare physician job satisfaction: facets relevant to the Indonesian system. HUMAN RESOURCES FOR HEALTH 2019; 17:38. [PMID: 31146752 PMCID: PMC6543658 DOI: 10.1186/s12960-019-0375-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 05/12/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Although there is extensive literature on the different aspects of physician job satisfaction worldwide, existing questionnaires used to measure job satisfaction in developed countries (e.g., the Job Satisfaction Scale) do not capture the aspects specific to Indonesian primary healthcare physicians. This is especially true considering the 2014 healthcare system reform, which led to the implementation of a national social health insurance scheme in Indonesia that has significantly changed the working conditions of physicians. Therefore, the current study aimed to identify aspects of primary care physician job satisfaction featured in published literature and determine those most suitable for measuring physician job satisfaction in light of Indonesia's recent reforms. METHODS A scoping literature review of full-text articles published in English between 2006 and 2015 was conducted using the PubMed, Psycinfo, and Web of Science databases. All aspects of primary care physician job satisfaction included in these studies were identified and classified. We then selected aspects mentioned in more than 5% of the reviewed papers and identified those most relevant to the post-reform Indonesian context. RESULTS A total of 440 articles were reviewed, from which 23 aspects of physicians' job satisfaction were extracted. Sixteen aspects were deemed relevant to the current Indonesian system: physical working conditions, overall job satisfaction, patient care/treatment, referral systems, relationships with colleagues, financial aspects, workload, time of work, recognition for good work, autonomy, opportunity to use abilities, relationships with patients, their families, and community, primary healthcare facilities' organization and management style, medical education, healthcare systems, and communication with health insurers. CONCLUSION Considering the recent reforms of the Indonesian healthcare system, existing tools for measuring job satisfaction among physicians must be revised. Future research should focus on the development and validation of new measures of physician job satisfaction based on the aspects identified in this study.
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Affiliation(s)
- Chatila Maharani
- Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
- Department of Public Health, Universitas Negeri Semarang, Semarang, Indonesia
| | - Hanevi Djasri
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Andreasta Meliala
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Mohamed Lamine Dramé
- Success in Africa, Conakry University Medical Faculty based think tank, Conakry, Guinea
| | - Michael Marx
- Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Svetla Loukanova
- Department of General Practice and Implementation Research, Medical Faculty, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
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Maharani C, Afief DF, Weber D, Marx M, Loukanova S. Primary care physicians' satisfaction after health care reform: a cross-sectional study from two cities in Central Java, Indonesia. BMC Health Serv Res 2019; 19:290. [PMID: 31068209 PMCID: PMC6505224 DOI: 10.1186/s12913-019-4121-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 04/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2014, Indonesia launched a mandatory national health insurance system called Jaminan Kesehatan Nasional (JKN). The reform introduced new conditions for primary care physicians (PCPs) that could influence their job satisfaction. This study assessed PCPs' satisfaction and its predictors in two cities in Central Java, Indonesia, following the reform. METHODS In this exploratory, cross-sectional study, we recruited 276 PCPs from the selected area. The data were all collected in 2016 using self-report questionnaires and interviews. PCPs' satisfaction was measured using a modified version of the Warr-Cook-Wall Job Satisfaction Scale which contains 19 items and uses a Likert-type response scale. Analysis of variance, the Kruskal-Wallis H test, both with Bonferroni corrections for post hoc testing, and Cochran-Mantel-Haenszel tests were used to compare overall job satisfaction between participant groups. We used simple and multiple linear regression analyses to identify the predictors of PCP satisfaction. Furthermore, a logistic regression analysis for binary outcome was applied to model the PCPs intention to leave practice. RESULTS PCPs' mean overall satisfaction level was 3.19 out of 5. They tended to be very satisfied with their relationship with colleagues, working hours, and physical working conditions. However, the PCPs were dissatisfied with the new referral system, the JKN health services standards, and JKN policy. The factors significantly associated with job satisfaction (p < 0.001) included type of practice, performance of managerial tasks, and PCPs' perceptions of and experiences with patients. PCP satisfaction was negatively associated (p = 0.004) with PCPs' intention to leave their practice. CONCLUSIONS The PCPs investigated in these two cities in Central Java had moderate satisfaction after the Indonesian health care reform. PCPs who worked in solo practices, performed managerial tasks, and had good experiences with patients tended to have higher satisfaction scores, which in turn prevented them from developing an intention to leave their practice. The three aspects that PCPs with which most dissatisfied were related with the JKN reform. Because of that, the government and BPJS for Health should aim to improve the JKN system in order to increase PCPs' satisfaction.
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Affiliation(s)
- Chatila Maharani
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Public Health, Universitas Negeri Semarang, Semarang, Indonesia
| | | | - Dorothea Weber
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Michael Marx
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Svetla Loukanova
- Department of General Practice and Implementation Research, University of Heidelberg, Heidelberg, Germany
- Department of General Practice and Health Services Research, Marsilius-Arkaden, Im Neuenheimer Feld 130.3, Turm West, 3 OG, Raum 03.303, D-69120 Heidelberg, Germany
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Kim CH, Chung CK, Kim MJ, Choi Y, Kim MJ, Shin S, Jung JM, Hwang SH, Yang SH, Park SB, Lee JH. Increased Volume of Surgery for Lumbar Spinal Stenosis and Changes in Surgical Methods and Outcomes: A Nationwide Cohort Study with a 5-Year Follow-Up. World Neurosurg 2018; 119:e313-e322. [PMID: 30053562 DOI: 10.1016/j.wneu.2018.07.139] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Examining spine surgery patterns over time is crucial to provide insights into variations and changes in clinical decision making. Changes in the number of surgeries, surgical methods, reoperation rates, and cost-effectiveness were analyzed for all patients who underwent surgery for lumbar spinal stenosis without spondylolisthesis in 2003 (2003 cohort) and 2008 (2008 cohort). METHODS The national health insurance database was used to create the 2003 cohort (n = 10,990) and 2008 cohort (n = 27,942). The surgical methods were classified into decompression and fusion surgery. The cumulative reoperation probability between those surgeries was calculated using the Kaplan-Meier method in the 2003 cohort and 2008 cohort. Comparison of the incremental cost-effectiveness ratios showed the additional direct cost of a 1% change in the reoperation probability. RESULTS The surgical volume increased 2.54-fold in the 2008 cohort. The age-adjusted number of surgeries per 1 million people increased 2.6-fold (from 154 in the 2003 cohort to 399 in the 2008 cohort) in aged patients and 1.9-fold (from 154 in the 2003 cohort to 291 in the 2008 cohort) in patients 20-59 years old in the 2008 cohort. The proportion of fusion surgeries increased from 20.3% in the 2003 cohort to 37.0% in the 2008 cohort. In total, the 5-year reoperation probabilities increased from 8.1% in the 2003 cohort to 11.2% in the 2008 cohort. Fusion decreased the reoperation probability by 1% at the cost of 1,711 U.S. dollars. CONCLUSIONS The increased numbers of spinal surgeries, fusion surgeries, and surgeries in older patients in a recent cohort were noteworthy. However, the increased surgical volume and fusion surgeries did not reduce the reoperation rate.
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Affiliation(s)
- Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Brain and Cognitive Sciences, Seoul National University, Gwanak-gu, Seoul, South Korea.
| | - Myo Jeong Kim
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service, Wonju, South Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Min-Jung Kim
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Sukyoun Shin
- Department of Customer Supporting Team, Samsung Life Insurance, Seocho-gu, Seoul, South Korea
| | - Jong-Myung Jung
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Sung Hwan Hwang
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Sung Bae Park
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University Boramae Hospital, Borame Medical Center Dongjak-gu, Seoul, South Korea
| | - Jun Ho Lee
- Department of Neurosurgery, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Dongdaemun-gu, Seoul, Republic of Korea
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12
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Increased Volume of Lumbar Surgeries for Herniated Intervertebral Disc Disease and Cost-Effectiveness Analysis: A Nationwide Cohort Study. Spine (Phila Pa 1976) 2018; 43:585-593. [PMID: 29095409 DOI: 10.1097/brs.0000000000002473] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of a nationwide database. OBJECTIVE The primary objective was to summarize the use of surgical methods for lumbar herniated intervertebral disc disease (HIVD) at two different time periods under the national health insurance system. The secondary objective was to perform a cost-effectiveness analysis by utilizing incremental cost-effectiveness ratio (ICER). SUMMARY OF BACKGROUND DATA The selection of surgical method for HIVD may or may not be consistent with cost effectiveness under national health insurance system, but this issue has rarely been analyzed. METHODS The data of all patients who underwent surgeries for HIVD in 2003 (n = 17,997) and 2008 (n = 38,264) were retrieved. The surgical methods included open discectomy (OD), fusion surgery, laminectomy, and percutaneous endoscopic lumbar discectomy (PELD). The hospitals were classified as tertiary-referral hospitals (≥300 beds), medium-sized hospitals (30-300 beds), or clinics (<30 beds). ICER showed the difference in the mean total cost per 1% decrease in the reoperation probability among surgical methods. The total cost included the costs of the index surgery and the reoperation. RESULTS In 2008, the number of surgeries increased by 2.13-fold. The number of hospitals increased by 34.75% (731 in 2003 and 985 in 2008). The proportion of medium-sized hospitals increased from 62.79% to 70.86%, but the proportion of surgeries performed at those hospitals increased from 61.31% to 85.08%. The probability of reoperation was highest after laminectomy (10.77%), followed by OD (10.50%), PELD (9.20%), and fusion surgery (7.56%). The ICERs indicated that PELD was a cost-effective surgical method. The proportion of OD increased from 71.21% to 84.12%, but that of PELD decreased from 16.68% to 4.57%. CONCLUSION The choice of surgical method might not always be consistent with cost-effectiveness strategies, and a high proportion of medium-sized hospitals may be responsible for this change. LEVEL OF EVIDENCE 4.
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13
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Kim SJ, Han KT, Kim W, Kim SJ, Park EC. Early Impact on Outpatients of Mandatory Adoption of the Diagnosis-Related Group-Based Reimbursement System in Korea on Use of Outpatient Care: Differences in Medical Utilization and Presurgery Examination. Health Serv Res 2017. [PMID: 28804904 DOI: 10.1111/1475‐6773.12749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore the impact of mandatory adoption of diagnosis-related groups (DRGs) on the use of outpatient care in Korea. DATA SOURCES National Health Claim data from 2,022 hospitals and 1,029,101 admission cases during 2011-2014: tonsillectomy/adenoidectomy, inguinal/femoral hernia operation, and hemorrhoidectomy. STUDY DESIGN Outcome variables included probability of outpatient visit, number of outpatient visits, and outpatient medical expenditures within 30 days. Presurgery examination before hospitalization for surgery, including basic and other examination, was conducted to evaluate a possible shift in health care service. A difference-in-difference research design was used to evaluate the impact of the DRG system on the use of outpatient care. PRINCIPAL FINDINGS Before the introduction of the DRG system, 384,609 (91.1 percent) participants used an outpatient clinic either before or after hospitalization. In our study, the number of outpatient visits and outpatient medical expenditures within 30 days increased after mandatory adoption of the DRG system. After adoption of the DRG system, volume and costs for presurgery examinations increased before hospitalization. CONCLUSION We observed a spillover effect after mandatory adoption of the DRG system. A future payment system should be designed for spillover effects, and the introduction of a new payment system that expands the DRG-based reimbursement system should be considered.
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Affiliation(s)
- Seung Ju Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Korea.,Institute of Health Services Research, Yonsei University, Seoul, Korea
| | - Kyu-Tae Han
- Research and Analysis Team, National Health Insurance Service Ilsan Hospital, Gyeonggi-do, Korea
| | - Woorim Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Korea.,Institute of Health Services Research, Yonsei University, Seoul, Korea
| | - Sun Jung Kim
- Department of Health Administration, Soonchunhyang University, Chungcheongnam-do, Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Korea.,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
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14
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Kim SJ, Han KT, Kim W, Kim SJ, Park EC. Early Impact on Outpatients of Mandatory Adoption of the Diagnosis-Related Group-Based Reimbursement System in Korea on Use of Outpatient Care: Differences in Medical Utilization and Presurgery Examination. Health Serv Res 2017; 53:2064-2083. [PMID: 28804904 DOI: 10.1111/1475-6773.12749] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To explore the impact of mandatory adoption of diagnosis-related groups (DRGs) on the use of outpatient care in Korea. DATA SOURCES National Health Claim data from 2,022 hospitals and 1,029,101 admission cases during 2011-2014: tonsillectomy/adenoidectomy, inguinal/femoral hernia operation, and hemorrhoidectomy. STUDY DESIGN Outcome variables included probability of outpatient visit, number of outpatient visits, and outpatient medical expenditures within 30 days. Presurgery examination before hospitalization for surgery, including basic and other examination, was conducted to evaluate a possible shift in health care service. A difference-in-difference research design was used to evaluate the impact of the DRG system on the use of outpatient care. PRINCIPAL FINDINGS Before the introduction of the DRG system, 384,609 (91.1 percent) participants used an outpatient clinic either before or after hospitalization. In our study, the number of outpatient visits and outpatient medical expenditures within 30 days increased after mandatory adoption of the DRG system. After adoption of the DRG system, volume and costs for presurgery examinations increased before hospitalization. CONCLUSION We observed a spillover effect after mandatory adoption of the DRG system. A future payment system should be designed for spillover effects, and the introduction of a new payment system that expands the DRG-based reimbursement system should be considered.
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Affiliation(s)
- Seung Ju Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Korea.,Institute of Health Services Research, Yonsei University, Seoul, Korea
| | - Kyu-Tae Han
- Research and Analysis Team, National Health Insurance Service Ilsan Hospital, Gyeonggi-do, Korea
| | - Woorim Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Korea.,Institute of Health Services Research, Yonsei University, Seoul, Korea
| | - Sun Jung Kim
- Department of Health Administration, Soonchunhyang University, Chungcheongnam-do, Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Korea.,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
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15
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Hahm MI, Chen HF, Miller T, O'Neill L, Lee HY. Why Do Some People Choose Opportunistic Rather Than Organized Cancer Screening? The Korean National Health and Nutrition Examination Survey (KNHANES) 2010-2012. Cancer Res Treat 2016; 49:727-738. [PMID: 27809458 PMCID: PMC5512382 DOI: 10.4143/crt.2016.243] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/11/2016] [Indexed: 12/24/2022] Open
Abstract
Purpose Although the Korean government has implemented a universal screening program for common cancers, some individuals choose to participate in opportunistic screening programs. Therefore, this study was conducted to identify factors contributing to the selection of organized versus opportunistic screening by the Korean general population. Materials and Methods Data from 11,189 participants aged ≥ 40 yearswho participated in the fifth Korean National Health and Nutrition Examination Survey (2010-2012) were analyzed in this study. Results A total of 6,843 of the participants (58.6%) underwent cancer screening, of which 6,019 (51.1%) participated in organized and 824 (7.5%) participated in opportunistic screening programs. Being female, older, highly educated, in the upper quartile of income, an ex-smoker, and a light drinker as well as having supplementary private health insurance and more comorbid conditions and engaging in moderate physical activity 1-4 days per week were related to participation in both types of screening programs. Being at least a high school graduate, in the upper quartile for income, and a light drinker, as well as having more comorbid conditions and engaging in moderate physical activities 1-4 days per week had a stronger effect on those undergoing opportunistic than organized screening. Conclusion The results of this study suggest that socioeconomic factors such as education and income, as well as health status factors such as health-related quality of life and number of comorbid conditions and health behaviors such as drinking and engaging in moderate physical activity 1-4 days per week had a stronger influence on participation in an opportunistic than in an organized screening program for cancer.
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Affiliation(s)
- Myung-Il Hahm
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Korea
| | - Hsueh-Fen Chen
- Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Thaddeus Miller
- Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Liam O'Neill
- Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Hoo-Yeon Lee
- Department of Social Medicine, Dankook University College of Medicine, Cheonan, Korea
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16
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Lee SM, Huh JS, Baek M, Yoo KH, Min GE, Lee HL, Lee DG. A nationwide epidemiological study of testicular torsion in Korea. J Korean Med Sci 2014; 29:1684-7. [PMID: 25469070 PMCID: PMC4248591 DOI: 10.3346/jkms.2014.29.12.1684] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 07/29/2014] [Indexed: 12/04/2022] Open
Abstract
Testicular torsion is a surgical emergency in the field of urology. Knowledge of the epidemiology and pathophysiology is significant to an urologist. However, the epidemiology of testicular torsion in Korea has not been studied. We performed a nationwide epidemiological study to improve knowledge of the epidemiology of testicular torsion. From 2006-2011, the Korean Urologic Association began the patient registry service. The annual number of patients with testicular torsion from 2006 to 2011 were 225, 250, 271, 277, 345, and 210, respectively. The overall incidence of testicular torsion in males was 1.1 per 100,000; However, the incidence in men less than 25 yr old was 2.9 per 100,000. Adolescents showed the highest incidence. Total testicular salvage rate was 75.7% in this survey. There was no geographic difference of testicular salvage rate. Minimizing the possibility of orchiectomy for testicular torsion is important to improve public awareness to expedite presentation and provider education to improve diagnosis and surgery.
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Affiliation(s)
- Sol Min Lee
- Department of Urology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung-Sik Huh
- Department of Urology, School of Medicine, Jeju National University, Jeju, Korea
| | - Minki Baek
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Koo Han Yoo
- Department of Urology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Gyeong Eun Min
- Department of Urology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyung-Lae Lee
- Department of Urology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Dong-Gi Lee
- Department of Urology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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Schmulson M, Corazziari E, Ghoshal UC, Myung SJ, Gerson CD, Quigley EMM, Gwee KA, Sperber AD. A four-country comparison of healthcare systems, implementation of diagnostic criteria, and treatment availability for functional gastrointestinal disorders: a report of the Rome Foundation Working Team on cross-cultural, multinational research. Neurogastroenterol Motil 2014; 26:1368-85. [PMID: 25087451 DOI: 10.1111/nmo.12402] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/22/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Variations in healthcare provision around the world may impact how patients with functional gastrointestinal disorder (FGIDs) are investigated, diagnosed, and treated. However, these differences have not been reviewed. PURPOSES The Multinational Working Team of the Rome Foundation, established to make recommendations on the conduct of multinational, cross-cultural research in FGIDs, identified seven key issues that are analyzed herein: (i) coverage afforded by different healthcare systems/providers; (ii) level of the healthcare system where patients with FGIDs are treated; (iii) extent/types of diagnostic procedures typically undertaken to diagnose FGIDs; (iv) physicians' familiarity with and implementation of the Rome diagnostic criteria in clinical practice; (v) range of medications approved for FGIDs and approval process for new agents; (vi) costs involved in treating FGIDs; and (vii) prevalence and role of complementary/alternative medicine (CAM) for FGIDs. Because it was not feasible to survey all countries around the world, we compared a selected number of countries based on their geographical and ethno-cultural diversity. Thus, we included Italy and South Korea as representative of nations with broad-based coverage of healthcare in the population and India and Mexico as newly industrialized countries where there may be limited provision of healthcare for substantial segments of the population. In light of the paucity of formal publications on these issues, we included additional sources from the medical literature as well as perspectives provided by local experts and the media. Finally, we provide future directions on healthcare issues that should be taken into account and implemented when conducting cross-cultural and multinational research in FGIDs.
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Affiliation(s)
- M Schmulson
- Laboratorio de Hígado, Páncreas y Motilidad (HIPAM)-Department of Experimental Medicine, Faculty of Medicine-Universidad Nacional Autónoma de México (UNAM), Hospital General de México, Mexico City, Mexico
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