Evaluating the effects of the 2017 National Health Insurance coverage expansion on amenable mortality and its disparities between areas in South Korea using Bayesian structural time-series models

To improve the low coverage rate of the National Health Insurance (NHI), South Korea implemented the NHI coverage expansion plan in 2017 to cover medically essential non-covered services and reduce copayment rates. This study aimed to estimate the effects of the 2017 NHI coverage expansion on amenable mortality and its disparities between areas in South Korea under a controlled interrupted time-series design using Bayesian structural time-series models. Age-standardized amenable mortality rates and rate differences (RDs) and rate ratios (RRs) between areas for amenable mortality were calculated monthly between July 2012 and December 2021 and used as the response series. The non-equivalent control series were monthly non-avoidable mortality rates and their regional disparities. After the coverage expansion, amenable mortality rates decreased for both males (-8.8%, 95% credible interval [CrI] -13.4% to -3.9%) and females (-8.3%, 95% CrI -13.4% to -2.4%), with the largest decline in the non-Seoul-Capital metropolitan area (-11.6%, 95% CrI -16.5% to -6.3%) rather than the Seoul Capital Area (-7.5%, 95% CrI -11.9% to -2.5%) and a non-significant reduction in the non-Seoul-Capital non-metropolitan area in females. RDs and RRs between areas for amenable mortality decreased non-significantly (-16.2%, 95% CrI -31.3% to 2.6% for RD and -1.2%, 95% CrI -3.7% to 1.5% for RR), except for a significant decrease in RD in males (-21.8%, 95% CrI -38.0% to -1.5%), and decreased less in females than in males. The coverage expansion was generally effective in reducing amenable mortality rates by area, but had limited effects in closing amenable mortality disparities between areas, favoring males and the non-Seoul-Capital metropolitan area. These results implied that additional measures are necessary to improve access to quality health care for females and underserved areas to enhance the effectiveness of the coverage expansion.

Trends and disparities in avoidable, treatable, and preventable mortalities in South Korea, 2001-2020: comparison of capital and non-capital areas

OBJECTIVES

This study aimed to describe the regional avoidable mortality trends in Korea and examine the trends in avoidable mortality disparities between the Seoul Capital Area and non-Seoul-Capital areas, thereby exploring the underlying reasons for the trend changes.

METHODS

Age-standardized mortality rates from avoidable causes between 2001-2020 were calculated by region. Regional disparities in avoidable mortality were quantified on both absolute and relative scales. Trends and disparities in avoidable mortality were analyzed using joinpoint regression models.

RESULTS

Avoidable, treatable, and preventable mortalities in Korea decreased at different rates over time by region. The largest decreases were in the non-Seoul-Capital non-metropolitan area for avoidable and preventable mortality rates and the non-Seoul- Capital metropolitan area for treatable mortality rates, despite the largest decline being in the Seoul Capital Area prior to around 2009. Absolute and relative regional disparities in avoidable and preventable mortalities generally decreased. Relative disparities in treatable mortality between areas widened. Regional disparities in all types of mortalities tended to improve after around 2009, especially among males. In females, disparities in avoidable, treatable, and preventable mortalities between areas improved less or even worsened.

CONCLUSIONS

Trends and disparities in avoidable mortality across areas in Korea seem to have varied under the influence of diverse social changes. Enhancing health services to underserved areas and strengthening gender-oriented policies are needed to reduce regional disparities in avoidable mortality.

Inappropriate Topical Antibiotics Use in Clean Dermatological Procedures in South Korea in 2018: A Nationwide Population-Based Cross-Sectional Study

BACKGROUND

The use of topical antibiotics (TA) for prophylactic purposes after clean dermatologic procedures (CDP) is generally not recommended, and the prescription of TA needs to be individualized in consideration of each patient's situation and underlying disease. The aim of this study was to determine the proportion of patients who underwent CDP in outpatient settings and were prescribed TA inappropriately, as well as the factors that may affect the prescription of TA.

METHODS

Outpatient visits coded for CDP were selected using claims data from the Health Insurance Review and Assessment Service in 2018. Of these, patients receiving TA prescriptions were classified as having inappropriate TA use, and the proportion was estimated through technical analysis. A logistic regression analysis was used to identify factors influencing inappropriate prescriptions.

RESULTS

Data were analyzed using 423,651 visits, and TA was prescribed for approximately 1.9% of the visits. TA usage was higher among women (2.0%), 0-19 years of age (2.2%), medical aid (2.2%), clinic settings (2.4%), and metropolitan areas (2.0%). TA was prescribed more frequently in urology (8.6%), pediatrics (5.0%), and dermatology (4.2%) than in other specialties.

CONCLUSION

The prescription rate of TA after CDP was 1.9% using the 1.4 million patient sample from the national health insurance claims data in Korea, which is equally weighted to represent 50 million people. Although the proportion of inappropriate TA prescriptions in Korea is lower than that in other nations, it cannot be overlooked because of the large number of cases. Efforts to improve quality are required to reduce the number of inappropriate prescriptions.

Effects of stricter drunk-driving laws on alcohol-related road traffic death, injury, and crash rates in South Korea: A synthetic counterfactual approach using Bayesian structural time-series models

In December 2018, new drunk-driving laws were enacted in Korea to impose stricter penalties and standards for driving under the influence of alcohol. This study aimed to estimate the effects of stricter drunk-driving laws on alcohol-related road traffic death, injury, and crash rates in Korea. Using police-reported traffic accident data and registered vehicle data from 2013 to 2020, monthly road traffic outcome rates were calculated: the response series involved alcohol-related rates and the non-equivalent control series involved total and non-alcohol-related rates. Based on a controlled interrupted time-series design using Bayesian structural time-series models, effects of the laws on alcohol-related road traffic outcome rates were evaluated. After implementation of these laws, the alcohol-related road traffic crash rate decreased by 14.3% (95% credible interval [CrI] -26.8% to -1.9%), alcohol-related road traffic injury rate by 17.6% (95% CrI -31.6% to -3.8%), and alcohol-related minor road traffic injury rate by 20.2% (95% CrI -32.4% to -7.7%). Alcohol-related road traffic death and severe injury rates also decreased more than the declining trends in the pre-period, but reduced non-significantly by 15.0% (95% CrI -47.2% to 17.3%) and 9.9% (95% CrI -33.9% to 14.5%), respectively. The mixed effectiveness of Korea's new drunk-driving laws on alcohol-related road traffic outcomes suggests that additional strategies are necessary to consistently and effectively reduce alcohol-related road traffic outcomes. More research is needed on ways to enhance the effectiveness of drunk-driving laws.

Travel time to emergency care not by geographic time, but by optimal time: A nationwide cross-sectional study for establishing optimal hospital access time to emergency medical care in South Korea

Increase in travel time, beyond a critical point, to emergency care may lead to a residential disparity in the outcome of patients with acute conditions. However, few studies have evaluated the evidence of travel time benchmarks in view of the association between travel time and outcome. Thus, this study aimed to establish the optimal hospital access time (OHAT) for emergency care in South Korea. We used nationwide healthcare claims data collected by the National Health Insurance System database of South Korea. Claims data of 445,548 patients who had visited emergency centers between January 1, 2006 and December 31, 2014 were analyzed. Travel time, by vehicle from the residence of the patient, to the emergency center was calculated. Thirteen emergency care-sensitive conditions (ECSCs) were selected by a multidisciplinary expert panel. The 30-day mortality after discharge was set as the outcome measure of emergency care. A change-point analysis was performed to identify the threshold where the mortality of ECSCs changed significantly. The differences in risk-adjusted mortality between patients living outside of OHAT and those living inside OHAT were evaluated. Five ECSCs showed a significant threshold where the mortality changed according to their OHAT. These were intracranial injury, acute myocardial infarction, other acute ischemic heart disease, fracture of the femur, and sepsis. The calculated OHAT were 71-80 min, 31-40 min, 70-80 min, 41-50 min, and 61-70 min, respectively. Those who lived outside the OHAT had higher risks of death, even after adjustment (adjusted OR: 1.04-7.21; 95% CI: 1.03-26.34). In conclusion, the OHAT for emergency care with no significant increase in mortality is in the 31-80 min range. Optimal travel time to hospital should be established by optimal time for outcomes, and not by geographic time, to resolve the disparities in geographical accessibility to emergency care.

Age-Period-Cohort Analysis of Trends in Infectious Disease Mortality in South Korea from 1983 to 2017

We aimed to describe the infectious disease (ID) mortality trends and evaluate age-period-cohort (APC) effects on ID mortality in Korea. Using cause-of-death and census population estimates data from 1983-2017, age-standardized ID mortality trends were investigated by joinpoint regression analysis. The APC effects on ID mortality were estimated using intrinsic estimator models. The age effect showed a J-shaped concave upward curve. Old age, especially ≥70 years, was a critical factor for ID deaths. Similar to the W-shaped period curve, ID mortality rapidly decreased due to economic development and the expansion of health coverage in the 1980s, decelerated with increasing inequality, surged due to the 1997 economic crisis, and has gradually increased since the mid-2000s. The cohort effect showed an inverted U-shape. The increasing cohort effect due to the deterioration of living standards led to a decreasing trend after the independence of Korea. Notwithstanding the slowdown during the 1950-1953 Korean War, educational expansion, economic growth, fertility reduction, and the improvement of ID-related policies might have led to a continued decline among the cohorts born since the 1960s. Diverse socioeconomic events may have influenced ID mortality trends in Korea via period and cohort effects. Policies to reduce the growing burden of ID deaths should be further improved.

Influence of trust on two different risk perceptions as an affective and cognitive dimension during Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in South Korea: serial cross-sectional surveys

OBJECTIVES

This study aimed to assess the affective and cognitive risk perceptions in the general population of Middle East respiratory syndrome (MERS) during the 2015 MERS coronavirus (MERS-CoV) outbreak in South Korea and the influencing factors.

DESIGN

Serial cross-sectional design with four consecutive surveys.

SETTING

Nationwide general population in South Korea.

PARTICIPANTS

Overall 4010 respondents (aged 19 years and over) from the general population during the MERS-CoV epidemic were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcome measures were (1) affective risk perception, (2) cognitive risk perception, and (3) trust in the government. Multivariate logistic regression models were used to identify factors (demographic, socioeconomic, area and political orientation) associated with risk perceptions.

RESULTS

Both affective and cognitive risk perceptions decreased as the MERS-CoV epidemic progressed. Proportions of affective risk perception were higher in all surveys and slowly decreased compared with cognitive risk perception over time. Females (adjusted OR (aOR) 1.72-2.00; 95% CI 1.14 to 2.86) and lower self-reported household economic status respondents were more likely to perceive the affective risk. The older the adults, the higher the affective risk perception, but the lower the cognitive risk perception compared with younger adults. The respondents who had low trust in the government had higher affective (aOR 2.19-3.11; 95 CI 1.44 to 4.67) and cognitive (aOR 3.55-5.41; 95 CI 1.44 to 9.01) risk perceptions.

CONCLUSIONS

This study suggests that even if cognitive risk perception is dissolved, affective risk perception can continue during MERS-CoV epidemic. Risk perception associating factors (ie, gender, age and self-reported household economic status) appear to be noticeably different between affective and cognitive dimensions. It also indicates that trust in the government influences affective risk perception and cognitive risk perception. There is a need for further efforts to understand the mechanism regarding the general public's risk perception for effective risk communication.

Trends in mortality from road traffic injuries in South Korea, 1983-2017: Joinpoint regression and age-period-cohort analyses

Although mortality trends can be influenced by different ages, periods, and cohorts, few studies have demonstrated the age-period-cohort (APC) effect on road traffic injury (RTI) mortality. Moreover, APC effects in Korea have never been documented despite the high mortality rates from RTIs. This study aimed to describe the trends in mortality from RTIs and examine APC effects on RTI mortality in Korea. Using the national death certificate and census mid-year population estimates data during 1983-2017, trends in age-standardized mortality rates from RTIs were analyzed using Joinpoint regression. Intrinsic estimator regression models were used to estimate APC effects on RTI mortality. Consistent with the trend in period effects, RTI mortality increased sharply with the economic growth in the 1980s, decelerated after the implementation of road safety policies in the early 1990s, plummeted owing to the 1997-1998 financial crisis, and gradually decreased from the early 2000s. A J-shaped age effect indicated that the relative risk of road traffic death surged in people aged ≥65 years. Educational expansion from the mid-1950s turned an increasing birth cohort effect into a continuously decreasing trend after peaking around the 1938-1943 birth cohorts. The risk of road traffic death was relatively high among the Korean Generation Y, i.e., those born in 1978-1983. RTI mortality trends in Korea have been affected by diverse socioeconomic changes through cohort and period effects. Despite the recent favorable trend, RTI mortality remains high, especially among older people. Road safety policies to address the burden of RTIs require further improvement.

Effects of educational policy on unhappiness of middle and high school students in Korea, 2006-2016

Background

Educational policies may have a substantial impact on health and well-being of students, who spend most of their daily lives at school. Policies on secondary education in Korea has changed in the late 2000s, which diversified college entrance exams (CEEs) and made the National Curriculum (NC) more autonomous to mitigate students’ burden of preparing for CEEs. This study aimed to estimate effects of educational policy changes on unhappiness, which is known to be associated with health status such as mortality, morbidity, and prognosis, of students in secondary education.

Methods

Using repeated cross-sectional self-reported data of 773,362 students in the Korea Youth Risk Behavior Web-based Survey during 2006-2016, cross-classified random effects models were fitted to estimate the fixed cohort effects of educational policy changes on unhappiness while considering individual factors and random effects of periods and grade cohorts.

Results

Students’ unhappiness increased when the NC began to become autonomous (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.03-1.42), but it increased less after the autonomous NC was fully applied (OR 1.14, 95% CI 0.92-1.42). Two times of diversification of CEEs increased unhappiness (OR 1.21, 95% CI 1.06-1.38 for the first diversification and OR 1.33, 95% CI 1.07-1.67 for the second diversification). Unhappiness was high in students with high stress level (OR 7.59, 95% CI 7.43-7.75), low academic performance (OR 1.48, 95% CI 1.44-1.52), and low household economic status (OR 2.32, 95% CI 2.26-2.39).

Conclusions

Enhancement of autonomy of the NC and diversification of CEEs increased students’ unhappiness. Educational policy changes that diversified competencies required for college admission might result in an increase in academic burden in the context of Korea, where entrance into prestigious universities is crucial for success in life. Improvement of educational policy is needed to increase students’ happiness.

Key messages

Educational policies may have a substantial impact on health and well-being of students, who spend most of their daily lives at school. Education policy changes in Korea increased students’ unhappiness, which might be due to an increase in academic burden resulted from diversification of competencies required for college admission.

Age, period, and cohort effects on infectious disease mortality in Korea, 1983-2017

Background

Infectious diseases are a leading cause of death worldwide, and constitute a significant burden of disease, even in developed countries including Korea. Although different ages, periods, and cohorts may affect mortality, few studies analyzed the epidemiologic pattern of infectious disease mortality considering these effects. This study aimed to estimate the age-period-cohort effects on infectious disease mortality in Korea.

Methods

The national death certificate and census mid-year population estimates data from 1983 to 2017 were categorized into 5-year age groups and 5-year periods. Infant deaths were excluded due to incomplete data. Intrinsic estimator regression models were fitted to estimate age-period-cohort effects on infectious disease mortality.

Results

A J-shaped age effect declined from age 1-4 years (intrinsic estimator coefficient [IEC] 0.68; 95% confidence interval [CI] 0.52, 0.85), the lowest at age 20-24 years (IEC -1.68; 95% CI -1.85, -1.51), and then increased with age. The declining trend of period effects was slowed down in 1998-2002 (after the 1997-1998 Asian economic crisis), and turned to an upward trend from 2008-2012 (after the 2008-2009 global financial crisis). The cohort effect increased from the earliest cohort born before 1905 (IEC -1.17, 95% CI -1.35, -0.98), peaked in the 1941-1945 cohort (IEC 1.20, 95% CI 1.10, 1.29), then plateaued out (IEC ranged from 0.93 to 1.10), and has continued to decline since the 1966-1970 cohort in which rapid economic growth began.

Conclusions

There were clear age, period, and cohort effects on infectious disease mortality in Korea. Through the period and cohort effects, the economic downturn and upturn might have increased or reduced infectious disease mortality, respectively. Recent upward trend in infectious disease mortality after the 2008-2009 financial crisis suggests a need to strengthen prevention and control of infectious diseases.

Key messages

It is important to consider age-period-cohort effects in identifying the epidemiologic pattern of infectious disease mortality trend and finding its underlying drivers. Economic cycle might have influenced infectious disease mortality through period and cohort effects.

How far is too far? A nationwide cross-sectional study for establishing optimal hospital access time for Korean pregnant women

OBJECTIVES

Access to a delivery unit is a major factor in determining maternal morbidity and mortality. However, there is little information about the optimal access time to a delivery unit. This study aimed to establish the optimal hospital access time (OHAT) for pregnant women in South Korea.

DESIGN

Nationwide cross-sectional study.

SETTING

We used the National Health Insurance System database of South Korea.

PARTICIPANTS

We analysed the data of 371 341 women who had experienced pregnancy in 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

Access time to hospital was defined as the time required to travel from the patient's home to the delivery unit. The incidence of obstetric complications was plotted against the access time to hospital. Change-point analysis was performed to identify the OHAT by determining a point wherein the incidence of obstetric complications changed significantly. As a final step, the risk of obstetric complications was compared by type among pregnant women who lived within the OHAT against those who lived outside the OHAT.

RESULTS

The OHAT associated with each adverse pregnancy outcomes were as follows: inadequate prenatal care, 41-50 min; preeclampsia, 51-60 min; placental abruption, 51-60 min; preterm delivery, 31-40 min; postpartum transfusion, 31-40 min; uterine artery embolisation, 31-40 min; admission to intensive care unit, 31-40 min; and caesarean hysterectomy, 31-40 min. Pregnant women who lived outside the OHAT had significantly higher risk for obstetric complications than those who lived within the OHAT.

CONCLUSIONS

Our results showed that the OHAT for each obstetric complication ranged between 31 and 60 min. The Korean government should take the OHAT under consideration when establishing interventions for pregnant women who live outside OHAT to reduce maternal morbidity and mortality.

Chasms in Achievement of Recommended Diabetes Care among Geographic Regions in Korea

BACKGROUND

Although effective care for type 2 diabetes (T2DM) is well known, considerable inadequate care has been still existed. Variations in achievement of the recommended quality indicators inT2DM care among small areas are not well known in Korea. This study examined the quality of care T2DM care and its geographical variations.

METHODS

We used the national health insurance database and national health screening database. Seven quality indicators were used to evaluate continuity of care (medication possession ratio), process of care (hemoglobin A1c test, lipid profile, microalbuminuria test, and eye examination), and intermediate outcome (blood pressure control, and low-density lipoprotein control). Crude and age-standardized proportions were calculated for each 252 districts in Korea.

RESULTS

All quality indicators failed to achieve the recommended level. Only about 3% and 15% of the patients underwent eye examination and microalbuminuria test, respectively. Other indicators ranged from 48% to 68%. Wide variation in the quality existed among districts and indicators. Eye examination and microalbuminuria test varied the most showing tenfold (0.9%-9.2%) and fourfold (6.3%-28.9%) variation by districts, respectively. There were 32.4 and 42.7 percentage point gap between the best and the worst districts in hemoglobin A1c test and blood pressure control, respectively.

CONCLUSION

Considerable proportion of T2DM patients were not adequately managed and quality of care varied substantially district to district. To improve the quality of diabetes care, it is necessary to identify the poor performance areas and establish a well-coordinated care system tailored to the need of the district.

Avoidable, amenable, and preventable mortalities in South Korea, 2000-2017: Age-period-cohort trends and impact on life expectancy at birth

This study aimed to estimate age-period-cohort effects on avoidable mortality and quantify the impact of avoidable mortality changes on life expectancy (LE) at birth in the South Korean population aged 0-74 years. Using death certificate and resident population data from 2000 to 2017, trends in age-standardized avoidable mortality rates were analyzed with joinpoint regression. Intrinsic estimator regression analysis was conducted to estimate age-period-cohort effects on avoidable mortality. Arriaga's method was used to measure the contributions of avoidable causes to changes in LE gaps between adjacent three-year periods by age and avoidable cause of death groups. Avoidable mortality decreased annually by 4.6% between 2000 and 2017. There were strong age and cohort effects and a weak period effect on avoidable mortality. In the overall decreasing trend, avoidable mortality declined less in cohorts born after the 1950-1953 Korean War and economic recession in the 1970s, with further reductions in cohorts born after the 1987 democratic reform and 1997-1998 economic crisis. Avoidable mortality was reduced after implementation of major health policies, but the decrease stagnated during the 2008-2009 financial crisis. Avoidable mortality reduction resulted in LE gains of 3.1 years, which accounted for 80% of total LE gains. Contribution to LE gains by causes of death was the largest for cerebrovascular disease. Major social changes and health policies influenced the avoidable mortality trend through cohort and period effects. Health care and public health policies implemented since the 2000s might have contributed substantially to gains in LE.

Preventive Behavioral Responses to the 2015 Middle East Respiratory Syndrome Coronavirus Outbreak in Korea

This study examined the public’s preventive behavioral responses during the 2015 Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in Korea and the influencing factors. Two cross-sectional telephone surveys were conducted by Gallup Korea using random digit dialing in June 2015 (n = 2004). The main outcome variables were nonpharmaceutical preventive measures (survey (1): Measures for reducing transmission (handwashing, face masks); and survey (2): Measures for avoiding contact with others). Multiple logistic regression was used to identify the factors influencing preventive behaviors. In survey (1), 60.3% of respondents reported more frequent handwashing and 15.5% reported wearing face masks at least once due to the MERS-CoV epidemic. In survey (2), 41–56% of respondents reported practicing avoidance measures. The concerned group was more likely to practice reducing transmission measures (odds ratio (OR) 4.5; 95% confidence interval (CI) 3.3–6.1) and avoidance measures (OR = 9.6; 95% CI, 6.4–14.4). The respondents who had low trust in president or ruling party had a higher practice rate of reducing transmission measures (OR = 1.7; 95% CI, 1.2–2.6) and avoidance measures (OR = 2.1; 95% CI, 1.2–3.5). Cooperative prevention measures need appropriated public concern based on effective risk communication.

Contextual Association between Political Regime and Adolescent Suicide Risk in Korea: A 12-year Repeated Cross-Sectional Study from Korea

This study evaluated associations between contextual political determinants and individual adolescent suicide risk (SR). Using repeated cross-sectional individual-level data of 829,861 students in the Korea Youth Risk Behavior Web-based Survey and national contextual-level data during 2005⁻2016, cross-classified random effects models were conducted to estimate fixed period and cohort effects of political determinants on SR. Adolescent SR was reduced during conservative presidential regimes. Contrary to presidencies' period effects, conservative regimes had negative cohort effects on adolescent SR. The odds of suicide attempt and depression increased in the grade cohorts affected by college entrance examination policies of conservative regimes. Politics has significantly impacted adolescent SR despite differences in period and cohort effects of politics. These findings imply the need to encourage adolescents' political participation in choosing political forces with policies favorable to their own mental health.

Accessibility of Prenatal Care Can Affect Inequitable Health Outcomes of Pregnant Women Living in Obstetric Care Underserved Areas: a Nationwide Population-Based Study

BACKGROUND

As of 2011, among 250 administrative districts in Korea, 54 districts did not have obstetrics and gynecology clinics or hospitals providing prenatal care and delivery services. The Korean government designated 38 regions among 54 districts as "Obstetric Care Underserved Areas (OCUA)." However, little is known there are any differences in pregnancy, prenatal care, and outcomes of women dwelling in OCUA compared to women in other areas. The purposes of this study were to compare the pregnancy related indicators (PRIs) and adequacy of prenatal care between OCUA region and non-OCUA region.

METHODS

Using National Health Insurance database in Korea from January 1, 2012 to December 31, 2014, we constructed the whole dataset of women who terminated pregnancy including delivery and abortion. We assessed incidence rate of 17 PRIs and adequacy of prenatal care. All indicators were compared between OCUA group and non-OCUA group.

RESULTS

The women dwelling in OCUA regions were more likely to get abortion (4.6% in OCUA vs. 3.6% in non-OCUA) and receive inadequate prenatal care (7.2% vs. 4.4%). Regarding abortion rate, there were significant regional differences in abortion rate. The highest abortion rate was 10.3% and the lowest region was 1.2%. Among 38 OCUA regions, 29 regions' abortion rates were higher than the national average of abortion rate (3.56%) and there were 10 regions in which abortion rates were higher than 7.0%. In addition, some PRIs such as acute pyelonephritis and transfusion in obstetric hemorrhage were more worse in OCUA regions compared to non-OCUA regions.

CONCLUSION

PRIs are different according to the regions where women are living. The Korean government should make an effort reducing these gaps of obstetric cares between OCUA and non-OCUA.

Natural course of new-onset urticaria: Results of a 10-year follow-up, nationwide, population-based study

BACKGROUND

Previous epidemiologic studies of the natural course of urticaria mainly focused on chronic spontaneous urticaria and were conducted at hospitals. The natural course of new-onset urticaria in the general population is unknown.

METHODS

Patients with new-onset urticaria were identified from the National Health Insurance Service-National Sample Cohort data. Patients who had at least one visit for urticaria in 2002 and 2003 were excluded and the study cohort consisted of 1,027,620 subjects with no history of urticaria. We analyzed cumulative incidences of urticaria, chronic urticaria, and chronic urticaria remission using the life table estimation method from 2004 to 2013. Their association with related factors was analyzed using the Cox proportional hazards analysis.

RESULTS

From 2004 to 2013, a total of 49,129 patients with new-onset urticaria were identified. The 10-year cumulative incidence rate of urticaria for the general population was 4.9% and that of chronic urticaria among patients with new-onset urticaria was 7.8%. Remission rates of chronic urticaria were 52.6% at 1 year and 88.9% at 5 years. Age, sex, residential area, and autoimmune thyroid disease were significantly associated with urticaria or chronic urticaria, but not with chronic urticaria remission, after adjusting for covariates. Female individuals were more likely to have new-onset urticaria but less likely to develop chronic urticaria compared with male individuals.

CONCLUSIONS

During the 10-year follow-up period, only a small proportion of patients with new-onset urticaria developed chronic urticaria. Remission was achieved in the majority of patients with chronic urticaria regardless of demographic characteristics or accompanying thyroid disease.

Rethinking the Role of the Public Health Clinic: Comparison of Outpatient Utilization in the Public Health Clinics and Private Clinics in Korea

Korea has experienced an overall expansion of access to care in the past few decades, which necessitated the reconsideration of the role of the public health clinics (PHC) as a primary care provider. The recent controversy about the outpatient copayment waiver for the elderly in the PHC is in the same vein. This study compared the outpatient utilization of the PHC and private clinics, and investigated its factors. Data were acquired from the National Patient Sample in 2013. Compared with private clinics, the patients in the PHC were more elderly and had less severe conditions. Being elderly, the status of National Health Insurance (NHI) beneficiaries, less comorbidities, and low total claim costs were found to be factors for choosing the PHC over private clinics. These results suggest that the elderly, who are the main beneficiaries of copayment waivers in the PHC, are the most likely to use the outpatient service by the PHC. The functions of the PHC need to be rearranged according to the recent advancements in the health care system in Korea. Diverting the resources and efforts from outpatient care to functions that best serve the health of the population should be considered.

Primary Care Patients' Preference for Hospitals over Clinics in Korea

Korea is in a unique condition to observe whether patients, when equal access to the levels of health care facilities is guaranteed by the support of the national health insurance, choose the appropriate levels of health care facilities. This study was performed to investigate the primary care patients’ preference for hospitals over clinics under no restriction for their choice. We used the 2011 National Inpatient Sample database of the Health Insurance Review and Assessment Service in Korea. A primary care patient was defined as a patient who visited as an outpatient in health care facilities with one of the 52 minor conditions defined by the Korean government. We found that approximately 15% of outpatient visits of the patients who were eligible for primary care in Korea happened in hospitals. In terms of cost, the outpatient visits in hospitals accounted for about 29% of total cost of outpatient visits. This arbitrary access to hospitals can lead to an inefficient use of health care resources. In order to ensure that health care facilities are stratified in terms of access as well as size and function, interventions to distribute patients to the appropriate level of care are required.

Symptom clusters and treatment time delay in Korean patients with ST-elevation myocardial infarction on admission

Most patients with acute myocardial infarction (AMI) experience more than one symptom at onset. Although symptoms are an important early indicator, patients and physicians may have difficulty interpreting symptoms and detecting AMI at an early stage. This study aimed to identify symptom clusters among Korean patients with ST-elevation myocardial infarction (STEMI), to examine the relationship between symptom clusters and patient-related variables, and to investigate the influence of symptom clusters on treatment time delay (decision time [DT], onset-to-balloon time [OTB]). This was a prospective multicenter study with a descriptive design that used face-to-face interviews. A total of 342 patients with STEMI were included in this study. To identify symptom clusters, two-step cluster analysis was performed using SPSS software. Multinomial logistic regression to explore factors related to each cluster and multiple logistic regression to determine the effect of symptom clusters on treatment time delay were conducted. Three symptom clusters were identified: cluster 1 (classic MI; characterized by chest pain); cluster 2 (stress symptoms; sweating and chest pain); and cluster 3 (multiple symptoms; dizziness, sweating, chest pain, weakness, and dyspnea). Compared with patients in clusters 2 and 3, those in cluster 1 were more likely to have diabetes or prior MI. Patients in clusters 2 and 3, who predominantly showed other symptoms in addition to chest pain, had a significantly shorter DT and OTB than those in cluster 1. In conclusion, to decrease treatment time delay, it seems important that patients and clinicians recognize symptom clusters, rather than relying on chest pain alone. Further research is necessary to translate our findings into clinical practice and to improve patient education and public education campaigns.

Gender Differences in Factors Related to Prehospital Delay in Patients with ST-Segment Elevation Myocardial Infarction

PURPOSE

The aim of our study was to investigate gender differences in factors related to prehospital delay and identify whether the knowledge of acute myocardial infarction symptoms affects this delay in Korean patients with ST-elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

A total of 350 patients (286 men, 64 women) with confirmed STEMI were interviewed to investigate socio-demographics, history of disease, symptom onset time, and factors that contributed to delayed decision time in seeking treatment and hospital arrival time from symptom onset. Factors associated with prehospital delay were examined separately by gender using univariate and multivariate analyses.

RESULTS

Female patients had higher proportions of ≥60-minute decision time and ≥120-minute arrival time compared to male patients (33.9% vs. 23.1%, 60.9% vs. 52.1%, respectively). However, the difference was not statistically significant (p=0.093 and 0.214, respectively). Previous cardiovascular disease (CVD) was associated with increased decision time in men, whereas, in women, lower educational status caused a greater delay in decision time. Factors associated with hospital arrival time excluding delayed decision time were referral from another hospital, previous CVD, and percutaneous coronary intervention in men, and referral from another hospital in women.

CONCLUSION

Gender differences exist in factors related to prehospital delay. Therefore, public education to reduce prehospital delay should be conducted according to gender with a focus on the pertinent factors.

Defining the activities of publicness for Korea's public community hospitals using the Delphi method

This study aims to identify which activities of a public community hospital (PHC) should be included in their definition of publicness and tries to achieve a consensus among experts using the Delphi method. We conduct 2 rounds of the Delphi process with 17 panel members using a developed draft of tentative activities for publicness including 5 main categories covering 27 items. The questions remain the same in both rounds and the applicability of each of the 27 items to publicness is measured on a 9-point scale. If the participants believe government funding is needed, we ask how much they think the government should support each item on a 0% to 100% scale. After conducting 2 rounds of the Delphi process, 22 out of the 27 items reached a consensus as activities defining the publicness of the PHCs. Among the 5 major categories, in category C, activities preventing market failure, all 10 items were considered activities of publicness. Nine of these were evaluated as items that should be compensated at 100% of total financial loss by the Korean government. Throughout results, we were able to define the activities of the PCH that encompassed its publicness and confirm that there are "good deficits" in the context of the PCHs. Thus, some PCH deficits are unavoidable and not wasted as these monies support a necessary role and function in providing public health. The Korean government should therefore consider taking actions such as exempting such "good deficits" or providing additional financial aid to reimburse the PHCs for "good deficits."

Determinants of Attitude toward the Public Health Spending and Its Relationship with Voting Behavior in the 2012 South Korean Presidential Election

This study aimed to identify the factors influencing South Korean voters' attitudes towards increasing public expenditure on health and to identify whether the issue of healthcare expenditure influenced candidate choice in the 2012 Korean presidential election. The study used the data from a survey conducted by the Institute of Korean Politics at Seoul National University immediately following the 2012 presidential election. The survey was completed by a nationwide sample of 1,200 people aged 19 or over using a face-to-face interview method and proportional quota sampling based on sex, age, and region. About 44.3% of respondents had a positive attitude toward increasing public health expenditure. There was no significant difference by the candidate they supported (conservative Park Geun-hye or liberal Moon Jae-in). In particular, even 44.9% of conservative supporters agreed with more spending. Politically neutral respondents (OR = 1.76, 90% CI 1.22-2.54) and strong conservative party supporters (OR = 1.53, 90% CI 1.05-2.25) were more likely to support public health expenditure increase compared to strong liberal party supporters. Also, respondents who believed that the economic gap in the country was widening were 1.91 times more likely to support an increase in public health expenditures. However, the issue of health expenditure had no influence on voters' choice of presidential candidates, and in particular no negative effect of choice of the ruling (conservative) party's candidate. Our results should be interpreted with care; one possible reason for this lack of effect might be that constituents voted along partisan lines regardless of their attitude to the welfare issue; another possible explanation might be the success of the "left click strategy" of the conservative party. That is, the conservatives did not reject economic democratization or social welfare expansion. Further research should be done to explain why attitudes to health spending did not directly affect choice of candidate.

Finding the Primary Care Providers in the Specialist-Dominant Primary Care Setting of Korea: A Cluster Analysis

Objective

This study aimed to identify private clinics that have a potential to perform the role of primary care providers (PCPs) in a primary care setting in Korea where private specialists are dominant.

Methods

The 2013 National Patient Sample claim data of Health Insurance Review and Assessment Service in Korea was used. Two-step cluster analysis was performed using characteristics of private clinics, and patient and utilization characteristics of 27,797 private clinics. External validation of clusters was performed by assessing the association among clusters and outcomes of care provided by private clinics. Stability of clusters was cross-validated using discriminant analysis.

Results

The result classified more than a half of private clinics into a potential PCP cluster. These were private clinics with specialties considered to be those of primary care physicians and were more likely to be located in non-metropolitan areas than specialized PCPs were. Compared to specialized PCPs, they had a higher percentage of pediatric and geriatric patients, patients with greater disease severity, a higher percentage of patients with complex comorbidities or with simple or minor disease groups, a higher number of patients and visits, and the same or higher quality of primary care. The most important factor in explaining variations between PCP clusters was the number of simple or minor disease groups per patient.

Conclusion

This study identified potential PCPs and suggested the identifying criteria for PCPs. It will provide useful information for formulation of a primary care strengthening policy to policy makers in Korea as well as other countries with similar specialist-dominant primary care settings.

Effects of deregulation of the driving licence application process on road safety in Korea: an interrupted time-series analysis

BACKGROUND

Road traffic deaths (RTDs) remain the 9th most common cause of mortality in South Korea despite their decreasing trends in high-income countries. In 2010 and 2011, the Korean government deregulated the process for obtaining a driving licence, and there has been significant concern that such deregulation of the driving licence policy could reduce road safety. This study aimed to explore the effects of the deregulation of driving licence policy on road safety by examining the incidence of road traffic collisions (RTCs), road traffic injuries (RTIs) and RTDs.

METHODS

The monthly incidence of RTCs, RTIs and RTDs was generated by using numbers of RTCs, RTIs and RTDs as numerators and numbers of registered vehicles as denominators. Changes in incidence since the deregulation implementation in February 2010 (phase I) and June 2011 (phase II) were evaluated via interrupted time-series analysis.

RESULTS

The second deregulation phase demonstrated significant changes in numbers of RTCs and RTIs: numbers of RTCs and RTIs decreased until they began to increase in November 2011. Since then, the monthly incidence of RTCs and RTIs have increased by 133.5 and 123.8 per 100 000 vehicles per month, respectively (p<0.05). RTD secular trends began to increase consecutively at rates of 0.024 (June 2010), 0.018 (between July 2010 and June 2011) and 0.273 (July 2011 onward) per 100 000 vehicles per month. Over the entire study period, the RTD incidence rate increased by 0.018 deaths per month on average subsequent to the first deregulation phase (p<0.05).

CONCLUSIONS

The deregulation policies that simplified the driving licence process were associated with increased incidence of RTCs, RTIs and RTDs in Korea.

General internists' perspectives regarding primary care and currently related issues in Korea

Although primary care has been recognized as an essential element of the healthcare system, the primary healthcare of Korea has not been highly valued. Listening to the voices of physicians who are engaged in primary care should be the first step for improving the level of primary care in Korea. In this study, we conducted a questionnaire survey of general internists to investigate their perspectives regarding primary care, and which included the evaluation of current primary care, perception of the five, key attributes of primary care, and their opinions regarding the management system of chronic diseases. A total of 466 general internists' responses were used in this analysis. The results showed that primary care is considered to have an important role, according to general internists, although their evaluation of the overall status of primary care in Korea indicated that it is poor. The respondents also indicated that the functions of coordination and comprehensiveness in primary care, which can be integral for treating patients with chronic diseases, are most vulnerable. Given the high level of agreement regarding the need for a new medical management system for chronic diseases, based on physicians' autonomy and provided by clinics, establishing a policy encouraging the participation of general internists should be emphasized.

Evidence of a broken healthcare delivery system in korea: unnecessary hospital outpatient utilization among patients with a single chronic disease without complications

This study aims to estimate the volume of unnecessarily utilized hospital outpatient services in Korea and quantify the total cost resulting from the inappropriate utilization. The analysis included a sample of 27,320,505 outpatient claims from the 2009 National Inpatient Sample database. Using the Charlson Comorbidity Index (CCI), patients were considered to have received 'unnecessary hospital outpatient utilization' if they had a CCI score of 0 and were concurrently admitted to hospital for treatment of a single chronic disease - hypertension (HTN), diabetes mellitus (DM), or hyperlipidemia (HL) - without complication. Overall, 85% of patients received unnecessary hospital services. Also hospitals were taking away 18.7% of HTN patients, 18.6% of DM and 31.6% of HL from clinics. Healthcare expenditures from unnecessary hospital outpatient utilization were estimated at: HTN (94,058 thousands USD, 38.6% of total expenditure); DM (17,795 thousands USD, 40.6%) and HL (62,876 thousands USD, 49.1%). If 100% of patients who received unnecessary hospital outpatient services were redirected to clinics, the estimated savings would be 104,226 thousands USD. This research proves that approximately 85% of hospital outpatient utilizations are unnecessary and that a significant amount of money is wasted on unnecessary healthcare services; thus burdening the National Health Insurance Service (NHIS) and patients.

Effect of repeated public releases on cesarean section rates

OBJECTIVES

Public release of and feedback (here after public release) on institutional (clinics and hospitals) cesarean section rates has had the effect of reducing cesarean section rates. However, compared to the isolated intervention, there was scant evidence of the effect of repeated public releases (RPR) on cesarean section rates. The objectives of this study were to evaluate the effect of RPR for reducing cesarean section rates.

METHODS

From January 2003 to July 2007, the nationwide monthly institutional cesarean section rates data (1,951,303 deliveries at 1194 institutions) were analyzed. We used autoregressive integrated moving average (ARIMA) time-series intervention models to assess the effect of the RPR on cesarean section rates and ordinal logistic regression model to determine the characteristics of the change in cesarean section rates.

RESULTS

Among four RPR, we found that only the first one (August 29, 2005) decreased the cesarean section rate (by 0.81 percent) and continued to have an impact period through the last observation in May 2007. Baseline cesarean section rates (OR, 4.7; 95% CI, 3.1 to 7.1) and annual number of deliveries (OR, 2.8; 95% CI, 1.6 to 4.7) of institutions in the upper third of each category at before first intervention had a significant contribution to the decrease of cesarean section rates.

CONCLUSIONS

We could not found the evidence that RPR has had the significant effect of reducing cesarean section rates. Institutions with upper baseline cesarean section rates and annual number of deliveries were more responsive to RPR.

[The change in readmission rate, length of stay and hospital charge after performance reporting of hip hemiarthroplasty]

OBJECTIVES

We assessed impact of performance reporting information about the readmission rate, length of stay and cost of hip hemiarthroplasty.

METHODS

The data are from a nationwide claims database, National Quality Improvement Project database, of Health Insurance Review & Assessment Service in Korea. From January 2006 to April 2008, we received information of length of stay, readmission within 30 days, cost of 22 851 hip hemiarthroplasty episodes. Each episodes has retained the diagnoses of comorbidities and demographics. We used time-series analysis to assess the shifting of patients selections, between high volume(over 16 operations in a year) and low volume institutions, after performance reporting (december 2007). The changes of quality (readmission, length of stay) and cost were evaluated by multilevel analysis with adjustment of patient's factors and institutional factors after performance reporting.

RESULTS

As compared with the before performance reporting, the proportion of patients who choose the high volume institution, increased 3.45% and the trends continued 4 months at marginal significance (p=0.059). After performance reporting, national average readmission rate, length of stay were decreased by 0.49 OR (95% CI=0.25-0.95) and 10% (β=-0.102 p<0.01) and cost was not changed (β=-0.01, p<0.27). The high volume institutions were more decreased than low volume in length of stay.

CONCLUSIONS

After performance reporting, readmission rate, length of stay were decreased and the patient selections were marginal shifted from low volume institutions to high volume institutions.

[Patterns of unintentional domestic injuries in Korea]

OBJECTIVES

To investigate the patterns of unintentional home injuries in Korea.

METHODS

The study population was 12,382,088 people who utilized National Health Insurance services due to injuries (main diagnosis codes S00 to T28) during 2006. Stratified samples(n=459,501) were randomly selected by sex, age group and severity of injury. A questionnaire was developed based on the International Classification of External Causes of Injury and 18,000 cases surveyed by telephone were analyzed after being projected into population proportionately according to the response rates of their strata. Domestic injury cases were finally included.

RESULTS

Domestic injuries (n=3,804) comprised 21.1% of total daily life injuries during 2006. Women were vulnerable to home injuries, with the elderly and those of lower income (medical-aid users) tending to suffer more severe injuries. Injury occurred most often due to a slipping fall (33.9%), overexertion (15.3%), falling (9.5%) and stumbling (9.4%), with severe injury most often resulting from slipping falls, falls and stumbles. Increasing age correlated with domestic injury-related disability.

CONCLUSIONS

The present findings provide basic information for development of home injury prevention strategies, with focus on the elderly.

[The incidence and patterns of unintentional injuries in daily life in Korea: a nationwide study]

OBJECTIVES

This study was conducted to estimate the cumulative incidence rate (CIR) of unintentional injuries in Korean daily life and to describe the pattern of unintentional injuries.

METHODS

The study population was the people who used the National Health Insurance because of injuries (ICD code: S00-T98) during 2006. The stratified sample according to gender, age and the severity of injury (NISS, New Injury Severity Score) was randomly selected. The questions on the questionnaire were developed as a reference for an international classification tool (ICECI, International Classification of External Causes of Injury). The questions included the locations of injury, the mechanisms of injury and the results of injury. Moreover, we used age, gender, region and income variables for analysis.

RESULTS

The CIR of unintentional injuries that occurred in daily life for 1 year per 100,000 persons was 17,606, and the CIR of severe injuries was 286. Many injuries were occurred at home (29.6%), public places (19.0%), school (13.7%) and near home (12.0%). The major mechanisms of injuries were slipping (48.8%), contact (14.0%), physical over-exertion (13.8%), and fall (6.6%). Infants and old aged people were vulnerable to injuries, and those who lived rural area and who were in a low income level were vulnerable too.

CONCLUSIONS

We signified the risk groups and risk settings of unintentional injuries in Korean daily life. These results could contribute to establishing strategies for injury prevention and implementing these strategies.

[Differences in medical care utilization rates of the disabled and the non-disabled with ambulatory care sensitive conditions]

OBJECTIVES

The purpose of this study was to determine whether the disabled have worse access to primary care than the non-disabled.

METHODS

We used the National Disability Registry data and the National Health Insurance data for the calendar year 2003, and we analyzed 807,380 disabled persons who had been registered until December 2001 and we also analyzed 1,614,760 non-disabled persons for nine ambulatory care sensitive conditions (ACSCs). The rates of physician visits and hospitalizations for the patients with ACSCs were compared between the disabled and the non-disabled. Multiple logistic regression analysis was used to evaluate the association between medical care utilization and disability and to assess the association between hospitalization and the number of physician visits while controlling for potential confounders.

RESULTS

The numbers of physician visits per 100 patients were 0.78-0.97 times lower for the disabled than that for the non-disabled with five of nine ACSCs. The numbers of hospitalizations per 100 patients were 1.16-1.77 times higher for the disabled than that for the non-disabled with all the ACSCs. While the ORs of a physician visit for the disabled were significantly lower than that for the non-disabled with all the ACSCs (OR: 0.44-0.70), and the ORs of hospitalization for the disabled were significantly higher (OR: 1.16-1.89). The lower physician visit group (number of physician visits < or =1) was more likely to be hospitalized than the higher physician visit group (number of physician visits > or =2) (OR: 1.69-19.77). The effect of the physician visit rate on hospitalization was larger than the effect of disability on hospitalization.

CONCLUSIONS

The results suggest that the disabled were more likely to be hospitalized for ACSCs due to their lower access to primary care.