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IA Okwor C, Petrosyan Y, Lee C, Cooper C. History of alcohol use does not predict HCV direct acting antiviral treatment outcomes. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2022; 7:233-241. [PMID: 36337601 PMCID: PMC9629724 DOI: 10.3138/jammi-2021-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/10/2022] [Accepted: 02/23/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection and excessive alcohol consumption are leading causes of liver disease worldwide. Direct acting antivirals (DAAs) are well-tolerated treatments for HCV infections with high sustained virologic response (SVR) rates. There are limited data assessing the influence of alcohol use on DAA uptake and cure. METHODS We performed a retrospective analysis of patients followed at The Ottawa Hospital Viral Hepatitis Program between January 2014 and May 2020 to investigate the effect of excessive alcohol use history on DAA uptake and SVR rates. Additionally, we evaluated the incidence of concurrent comorbidities and social determinants of health. Predictors of DAA uptake and SVR were assessed by logistic regression. RESULTS Excessive alcohol use history was reported in 46.0% (733) of patients. Excessive alcohol use did not predict DAA uptake (OR 1.06, 95% CI 0.71 to 1.57), while employment (OR 2.10, 95% CI 1.29 to 3.42) and recreational drug use (OR 0.62, 95% CI 0.40 to 0.94) were predictors. Employment predicted SVR (OR 2.38, 95% CI 1.68 to 3.36) in those starting treatment. Excessive alcohol use history did not predict SVR. CONCLUSIONS History of excessive alcohol use does not influence treatment initiation or SVR. Efforts to improve treatment uptake should shift to focus on the roles of determinants of health such as employment and recreational drug use on treatment initiation.
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Affiliation(s)
| | | | - Craig Lee
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Curtis Cooper
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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The change in the nationwide seroprevalence of hepatitis C virus and the status of linkage to care in South Korea from 2009 to 2015. Hepatol Int 2019; 13:599-608. [PMID: 31432446 DOI: 10.1007/s12072-019-09975-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) requires epidemiological monitoring to estimate its disease burden and to develop countermeasures. This study aimed to investigate the difference between the 2015 and 2009 nationwide anti-HCV seroprevalence and to determine linkage to care estimates in South Korea. METHODS A total 268,422 examinees ≥ 20 years old were included in 2015 from 33 medical institutions nationwide. Electronically extracted data were retrospectively analyzed to calculate the age-, sex-, and area-adjusted anti-HCV prevalence. Seroprevalence in 2015 was measured using the same method as that in 2009. For anti-HCV-positive subjects, medical records were reviewed to see whether HCV RNA testing or antiviral treatment was performed. RESULTS Adjusted anti-HCV prevalence was 0.60% (95% confidence interval, 0.57-0.63) based on general Korean population in 2015. It showed an increasing trend according to age; 0.23% in thirties, 0.38% in forties, 0.63% in fifties, 1.08% in sixties, and 1.65% in those aged ≥ 70 years. From 2009 to 2015, the adjusted anti-HCV prevalence decreased by 30%, with odds ratio of 0.70 (95% CI 0.70-0.71). There was significant intranational regional variation and changing pattern of seroprevalence. Among 1359 anti-HCV-positive subjects, HCV RNA test was performed in 60% and 25.4% had positivity. Treatment-initiated and cured rates in 2015 were 18.5% and 10.9%, respectively. CONCLUSIONS Anti-HCV prevalence in South Korea was 0.6% in 2015, showing a 30% decrease from that in 2009. Although the HCV RNA testing rate was increased since 2009, this remains suboptimal. Moreover, the treatment uptake rate should be improved in South Korea.
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Liu CH, Yu ML, Peng CY, Hsieh TY, Huang YH, Su WW, Cheng PN, Lin CL, Lo CC, Chen CY, Chen JJ, Ma Q, Brooks-Rooney C, Kao JH. Real-world anti-viral treatment decisions among chronic hepatitis C patients in Taiwan: The INITIATE study. J Formos Med Assoc 2018; 118:1014-1023. [PMID: 30448077 DOI: 10.1016/j.jfma.2018.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/27/2018] [Accepted: 10/30/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/PURPOSE While direct-acting antiviral regimens have been approved for chronic hepatitis C (CHC) patients in Taiwan, reimbursement is limited to certain populations. Thus, pegylated interferon plus ribavirin (PEG-IFN/RBV) remains the standard of care for many patients. The aim of this study was to investigate the percentage of CHC patients who were recommended and willing to receive PEG-IFN/RBV, and to identify reasons why patients were not recommended or unwilling to receive treatment. METHODS 822 Taiwanese CHC patients were enrolled from May-August 2016 in this cross-sectional study. PEG-IFN/RBV recommendation and patient willingness to receive treatment were evaluated through surveys. Patient characteristics associated with treatment recommendation and willingness were assessed. RESULTS 311 (37.8%) patients were recommended PEG-IFN/RBV while 102 (12.4%) were willing to follow treatment recommendation. Rates of recommendation and willingness were lower in treatment-experienced, hepatitis C virus genotype 1 (GT1) and cirrhotic patients, and those treated in Northern Taiwan. Multivariate analyses found factors such as prior treatment experience, GT1, cirrhosis and low hemoglobin levels to be associated with lower recommendation rates while advanced age, GT1 and low baseline viral loads were associated with lower willingness rates. Physicians' top reasons for not recommending PEG-IFN/RBV included the wish to wait for better treatment options (60.3%), prior treatment failure (21.3%) and patients' advanced age (20.9%). Patients were unwilling to receive treatment mainly due to concerns about side effects (91.4%), the wish to wait for better treatment options (71.3%) and inconvenience (25.4%). CONCLUSION A minority of Taiwanese CHC patients were recommended PEG-IFN/RBV, of which few were willing to receive treatment.
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Affiliation(s)
- Chen-Hua Liu
- National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Yuan Peng
- Department of Internal Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Tsai-Yuan Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Wen Su
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Pin-Nan Cheng
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chih-Lin Lin
- Department of Gastroenterology, Taipei City Hospital - Renai Branch, Taipei, Taiwan
| | - Ching-Chu Lo
- Department of Internal Medicine, St. Martin De Porres Hospital - Daya, Chiayi, Taiwan
| | - Chi-Yi Chen
- Department of Internal Medicine, Chiayi Christian Hospital, Chiayi, Taiwan
| | - Jyh-Jou Chen
- Department of Internal Medicine, Chi Mei Hospital, Liouying, Tainan, Taiwan
| | - Qian Ma
- Costello Medical Singapore Pte Ltd, Singapore
| | | | - Jia-Horng Kao
- National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
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Jang ES, Kim YS, Kim KA, Lee YJ, Chung WJ, Kim IH, Lee BS, Jeong SH. Factors Associated with Health-Related Quality of Life in Korean Patients with Chronic Hepatitis C Infection Using the SF-36 and EQ-5D. Gut Liver 2018; 12:440-448. [PMID: 29588435 PMCID: PMC6027832 DOI: 10.5009/gnl17322] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/28/2017] [Accepted: 11/07/2017] [Indexed: 12/14/2022] Open
Abstract
Background/Aims This study aimed to describe the health-related quality of life (HRQoL) outcomes for Korean chronic hepatitis C patients and to investigate the impact of patient and virus-related factors on HRQoL. Methods HRQoL was assessed in 235 hepatitis C virus (HCV)-infected patients from seven nationwide tertiary hospital, including those with liver cirrhosis and hepatocellular carcinoma (HCC), using the Shor-Form 36 (SF-36) version 2 and the European quality of life questionnaire-5 dimensions (EQ-5D-3L). Results The SF-36 physical (48.8±8.3) and mental (46.2±11.7) component summary scores of the HCV-infected patients were below normal limits. Of the eight domains, general health, vitality, and mental health tended to show low scores. Patients with decompensated cirrhosis had the lowest HRQoL, while HCC and chronic hepatitis patients had similar HRQoL results. The EQ-5D index was low (0.848±0.145) in the HCV infected patients. Multivariable analysis showed age ≤65 years, high monthly family income (>$2,641), low comorbidity score, and sustained virologic response (SVR) were independently associated with favorable HRQoL. Conclusions HRQoL in Korean patients with chronic HCV infection was low and was affected by cirrhosis severity, SVR, and comorbidity as well as income, which had the strongest effect. Therefore, HRQoL may be improved by antiviral therapy with reasonable costs to prevent cirrhosis progression.
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Affiliation(s)
- Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Kyung-Ah Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Youn Jae Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University College of Medicine, Jeonju, Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Ki M, Choi HY, Kim KA, Jang ES, Jeong SH. Healthcare Costs for Chronic Hepatitis C in South Korea from 2009 to 2013: An Analysis of the National Health Insurance Claims' Data. Gut Liver 2018; 11:835-842. [PMID: 28798283 PMCID: PMC5669600 DOI: 10.5009/gnl17034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/16/2022] Open
Abstract
Background/Aims The introduction of direct-acting antivirals (DAA) in 2013 revolutionized hepatitis C virus (HCV) treatment, offering a cure rate >90%. However, this therapy is expensive, and estimations of the number of chronic HCV-infected (CHC) patients and their treatment costs pre-2013 are therefore essential for creating policies and expanding drug access. Herein, we aimed to investigate the number of HCV-related liver disease patients, their healthcare utilization, their annual direct medical costs, and the interferon-based antiviral treatment rates and costs from 2009 to 2013 in South Korea. Methods The National Health Insurance database was reviewed, and patients diagnosed with CHC from 2009 to 2013 were extracted. Data regarding detailed healthcare utilization, prescribed drugs, and direct medical costs were obtained. For annual direct healthcare cost calculations, a prevalence-based approach was used. Results Overall, 181,768 CHC patients were identified. In 2013, the annual per-patient costs for chronic hepatitis, liver cirrhosis, hepatocellular carcinoma, and the first year post-liver transplant were 895, 1,873, 6,945, and 67,359 United States dollars, respectively. Interferon-based antiviral therapeutics were prescribed to 25,223 patients (13.9%). Conclusions Healthcare costs have increased remarkably with increasing liver disease severity. Thus, efforts to stop disease progression are needed. Moreover, the low rate of interferon-based therapy indicates an unmet need for DAA.
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Affiliation(s)
- Moran Ki
- Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Hwa Young Choi
- Department of Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Kyung-Ah Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Jang ES, Kim YS, Kim KA, Lee YJ, Chung WJ, Kim IH, Lee BS, Jeong SH. Final Report of Unmet Needs of Interferon-Based Therapy for Chronic Hepatitis C in Korea: Basis for Moving into the Direct-Acting Antiviral Era. Gut Liver 2018; 11:543-550. [PMID: 28506027 PMCID: PMC5491090 DOI: 10.5009/gnl16530] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 12/12/2022] Open
Abstract
Background/Aims To evaluate the era of direct acting antivirals (DAAs), we must understand the treatment patterns and outcomes of interferon-based therapy for hepatitis C virus (HCV) infection. We aimed to elucidate the treatment rate, factors affecting treatment decisions, and efficacy of interferon-based therapy in a real-world setting. Methods This nationwide cohort study included 1,191 newly diagnosed patients with chronic HCV infection at seven tertiary hospitals in South Korea. Subjects were followed retrospectively until March 2015, which was just before the approval of DAA therapy. Results In total, 48.2% and 49.3% of the patients had HCV genotypes 1 and 2, respectively. Interferon-based therapy was initiated in 541 patients (45.4%). The major reasons for no treatment included ineligibility (18.9%), concern about adverse events (22.3%), cost (21.5%), and an age >75 years (19.5%). Interferon-based therapy was discontinued (18.5%) mainly due to adverse events (n=66). The intent-to-treat analysis found that the sustained virologic response (SVR) rate was 58.3% in genotype 1 patients and 74.7% in non-genotype 1 patients. Conclusions Approximately one-third of newly diagnosed HCV patients in South Korea received interferon-based therapy and showed a suboptimal SVR rate. Diagnosis of patients at younger ages and with a less advanced liver status and reducing the DAA therapy cost may fulfill unmet needs.
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Affiliation(s)
- Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Kyung-Ah Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Youn Jae Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Vutien P, Jin M, Le MH, Nguyen P, Trinh S, Huang JF, Yu ML, Chuang WL, Nguyen MH. Regional differences in treatment rates for patients with chronic hepatitis C infection: Systematic review and meta-analysis. PLoS One 2017; 12:e0183851. [PMID: 28877190 PMCID: PMC5587234 DOI: 10.1371/journal.pone.0183851] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/12/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS Treatment rates with interferon-based therapies for chronic hepatitis C have been low. Our aim was to perform a systematic review of available data to estimate the rates and barriers for antiviral therapy for chronic hepatitis C. METHODS We conducted a systematic review and meta-analysis searching MEDLINE, SCOPUS through March 2016 and abstracts from recent major liver meetings for primary literature with available hepatitis C treatment rates. Random-effects models were used to estimate effect sizes and meta-regression to test for potential sources of heterogeneity. RESULTS We included 39 studies with 476,443 chronic hepatitis C patients. The overall treatment rate was 25.5% (CI: 21.1-30.5%) and by region 34% for Europe, 28.3% for Asia/Pacific, and 18.7% for North America (p = 0.008). On multivariable meta-regression, practice setting (tertiary vs. population-based, p = 0.04), region (Europe vs. North America p = 0.004), and data source (clinical chart review vs. administrative database, p = 0.025) remained significant predictors of heterogeneity. The overall treatment eligibility rate was 52.5%, and 60% of these received therapy. Of the patients who refused treatment, 16.2% cited side effects, 13.8% cited cost as reasons for treatment refusal, and 30% lacked access to specialist care. CONCLUSIONS Only one-quarter of chronic hepatitis C patients received antiviral therapy in the pre-direct acting antiviral era. Treatment rates should improve in the new interferon-free era but, cost, co-morbidities, and lack of specialist care will likely remain and need to be addressed. Linkage to care should even be of higher priority now that well-tolerated cure is available.
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Affiliation(s)
- Philip Vutien
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
- Rush University Medical Center, Chicago, Illinois, United States of America
| | - Michelle Jin
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
| | - Michael H. Le
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
| | - Pauline Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
| | - Sam Trinh
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
| | - Jee-Fu Huang
- Hepatobiliary Section, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Lung Yu
- Hepatobiliary Section, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wan-Long Chuang
- Hepatobiliary Section, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mindie H. Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, United States of America
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Kim DY, Han KH, Jun B, Kim TH, Park S, Ward T, Webster S, McEwan P. Estimating the Cost-Effectiveness of One-Time Screening and Treatment for Hepatitis C in Korea. PLoS One 2017; 12:e0167770. [PMID: 28060834 PMCID: PMC5218507 DOI: 10.1371/journal.pone.0167770] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 11/18/2016] [Indexed: 02/06/2023] Open
Abstract
Background and Aims This study aims to investigate the cost-effectiveness of a one-time hepatitis C virus (HCV) screening and treatment program in South Korea where hepatitis B virus (HBV) prevails, in people aged 40–70, compared to current practice (no screening). Methods A published Markov model was used in conjunction with a screening and treatment decision tree to model patient cohorts, aged 40–49, 50–59 and 60–69 years, distributed across chronic hepatitis C (CHC) and compensated cirrhosis (CC) health states (82.5% and 17.5%, respectively). Based on a published seroepidemiology study, HCV prevalence was estimated at 0.60%, 0.80% and 1.53%, respectively. An estimated 71.7% of the population was screened. Post-diagnosis, 39.4% of patients were treated with a newly available all-oral direct-acting antiviral (DAA) regimen over 5 years. Published rates of sustained virologic response, disease management costs, transition rates and utilities were utilised. Results Screening resulted in the identification of 43,635 previously undiagnosed patients across all cohorts. One-time HCV screening and treatment was estimated to be cost-effective across all cohorts; predicted incremental cost-effectiveness ratios ranged from $5,714 to $8,889 per quality-adjusted life year gained. Incremental costs associated with screening, treatment and disease management ranged from $156.47 to $181.85 million USD; lifetime costs-offsets associated with the avoidance of end stage liver disease complications ranged from $51.47 to $57.48 million USD. Conclusions One-time HCV screening and treatment in South Korean people aged 40–70 is likely to be highly cost-effective compared to the current practice of no screening.
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Affiliation(s)
- Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- * E-mail:
| | - Byungyool Jun
- Department of Preventive Medicine, Cha University College of Medicine, Kyung-Gi Province, South Korea
| | - Tae Hyun Kim
- Graduate School of Public Health, Yonsei University, Seoul, South Korea
| | - Sohee Park
- Graduate School of Public Health, Yonsei University, Seoul, South Korea
| | - Thomas Ward
- HEOR Ltd, Singleton Court Business Park, Monmouth, Wales, United Kingdom
| | - Samantha Webster
- HEOR Ltd, Singleton Court Business Park, Monmouth, Wales, United Kingdom
| | - Phil McEwan
- HEOR Ltd, Singleton Court Business Park, Monmouth, Wales, United Kingdom
- School of Human & Health Sciences, Swansea University, Wales, United Kingdom
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