The incidence and prevalence of diabetes mellitus and related atherosclerotic complications in Korea: a National Health Insurance Database Study

Association between metformin use and the risk of developing open-angle glaucoma among patients with diabetes: a retrospective cohort study and meta-analysis

PURPOSE

Recent studies examining the neuroprotective effects of metformin on open-angle glaucoma (OAG) have failed to provide consistent results. In this study, we investigated the association between metformin use and OAG.

METHODS

Data were obtained from a sample cohort of the Korean National Health Insurance database. Patients diagnosed with type-2 diabetes (T2DM) between 2004 and 2013 were included. We performed propensity score-matched analysis in a matched cohort (N = 20,646). The risk of the newly developed OAG was estimated using a Cox proportional hazards model. Including the present study, the meta-analysis included five studies to calculate the pooled risk for OAG based on metformin use.

RESULTS

In the adjusted model, the analysis revealed no statistical association between metformin use and OAG incidence (hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.79-1.40; P = 0.738). The highest tercile of metformin use demonstrated no statistical significance (HR 0.93 [95% CI 0.63-1.37]; P = 0.703). No significant dose-dependent association was observed between the cumulative dose and incidence of OAG (P-value for trend = 0.336). In a meta-analysis of four published articles and the present study, the common-effects and random-effects models indicated conflicting results in terms of significance. The random effects model demonstrated no significant association (pooled risk ratio 0.53; 95% CI 0.24-1.19; P = 0.123).

CONCLUSION

We found no significant association between metformin use and OAG incidence in patients with T2DM in this population-based cohort study and meta-analysis. Further studies are needed to investigate the association between metformin use and the risk of OAG among patients with T2DM.

PSORIASIS INCREASES RETINAL VEIN OCCLUSION RISK IN DIABETIC PATIENTS: A Nationwide Population-Based Study

PURPOSE

The objective of this research was to explore how psoriasis is linked to the occurrence of retinal vein occlusion (RVO) in diabetic population.

METHODS

This was a retrospective, nationwide, population-based cohort study that examined medical records from January 2009 to December 2012. The study focused on patients ≥20 years of age who had been diagnosed with Type 2 diabetes mellitus (DM). The authors compared the incidence rate of RVO between a group of patients with psoriasis and a group of patients without psoriasis until December 2018 in all subjects.

RESULTS

Of the 2,745,689 Type 2 DM patients, 23,725 patients were classified in the psoriasis group and the rest of the 2,547,121 individuals in the control group. A total of 497 RVO cases occurred in the psoriasis group (3.14/1,000 person-years) and 42,388 RVO cases in the control group (2.44/1,000 person-years). According to multivariable Cox proportional hazard models, individuals with psoriasis had a significantly greater risk of developing RVO compared with control subjects (hazard ratio: 1.216, 95% confidence interval: 1.11-1.33) after adjustments for covariates.

CONCLUSION

This study demonstrated that psoriasis was an independent risk factor for developing RVO in DM patients. Therefore, physicians need to be vigilant for the occurrence of RVO in DM patients who also have psoriasis.

Optimal Look-Back Period to Identify True Incident Cases of Diabetes in Medical Insurance Data in the Chinese Population: Retrospective Analysis Study

BACKGROUND

Accurate estimation of incidence and prevalence is vital for preventing and controlling diabetes. Administrative data (including insurance data) could be a good source to estimate the incidence of diabetes. However, how to determine the look-back period (LP) to remove cases with preceding records remains a problem for administrative data. A short LP will cause overestimation of incidence, whereas a long LP will limit the usefulness of a database. Therefore, it is necessary to determine the optimal LP length for identifying incident cases in administrative data.

OBJECTIVE

This study aims to offer different methods to identify the optimal LP for diabetes by using medical insurance data from the Chinese population with reference to other diseases in the administrative data.

METHODS

Data from the insurance database of the city of Weifang, China from between January 2016 and December 2020 were used. To identify the incident cases in 2020, we removed prevalent patients with preceding records of diabetes between 2016 and 2019 (ie, a 4-year LP). Using this 4-year LP as a reference, consistency examination indexes (CEIs), including positive predictive values, the κ coefficient, and overestimation rate, were calculated to determine the level of agreement between different LPs and an LP of 4 years (the longest LP). Moreover, we constructed a retrograde survival function, in which survival (ie, incident cases) means not having a preceding record at the given time and the survival time is the difference between the date of the last record in 2020 and the most recent previous record in the LP. Based on the survival outcome and survival time, we established the survival function and survival hazard function. When the survival probability, S(t), remains stable, and survival hazard converges to zero, we obtain the optimal LP. Combined with the results of these two methods, we determined the optimal LP for Chinese diabetes patients.

RESULTS

The κ agreement was excellent (0.950), with a high positive predictive value (92.2%) and a low overestimation rate (8.4%) after a 2-year LP. As for the retrograde survival function, S(t) dropped rapidly during the first 1-year LP (from 1.00 to 0.11). At a 417-day LP, the hazard function reached approximately zero (ht=0.000459), S(t) remained at 0.10, and at 480 days, the frequency of S(t) did not increase. Combining the two methods, we found that the optimal LP is 2 years for Chinese diabetes patients.

CONCLUSIONS

The retrograde survival method and CEIs both showed effectiveness. A 2-year LP should be considered when identifying incident cases of diabetes using insurance data in the Chinese population.

Appropriate screening interval to detect the development of chronic metabolic diseases

AIMS

We conducted a cohort study to determine the screening intervals of metabolic disorders.

METHOD

Participants without diabetes mellitus (DM), hypertension (HTN), dyslipidemia, and abdominal obesity who underwent health examinations (2005-2019) in Korea were included. Participants were grouped according to baseline fasting glucose, LDL-C level, blood pressure (BP), and waist circumference (WC). The time to develop metabolic disorders and the percentile of survival time was assessed in each group.

RESULT

The median follow-up duration was 4.94 years (n = 222,413;mean age 37.13 ± 7.49 years). After 8.32(95 %CI 8.22-8.41), 3.01(2.89-3.31), and 1.11(1.03-1.25) years, 10 % of participants developed DM in fasting glucose levels of 100-110, 110-120, and 120-125 mg/dL, respectively. After 8.40(8.33-8.45), 6.33(6.20-6.47), and 1.99(1.97-2.00) years, 10 % developed HTN in BP 120/70, 120/70-130/80, and 130/80-140/90 mmHg, respectively. After 5.99(5.94-6.04), 2.84(2.77-2.90), and 1.36(1.30-1.44) years, 10 % developed dyslipidemia in LDL-C 100-120, 120-140, and 140-160 mg/dL, respectively. After 4.62(4.41-4.80) and 1.67(1.64-1.69) years, 10 % developed abdominal obesity in baseline WC < 80(Women;W)/85(Men;M) and < 85(W)/90(M) cm, respectively.

CONCLUSION

In adults aged 30-40, the screening interval of metabolic disorders should be individualized based on the baseline metabolic derangement. An individual with borderline values may need an annual screening.

Association of Uncontrolled Hypertension or Diabetes Mellitus With Major Adverse Cardiovascular Events and Mortality in South Korea: Population-Based Cohort Study

BACKGROUND

Managing hypertension (HT) and diabetes mellitus (DM) is crucial to preventing cardiovascular diseases. Few studies have investigated the incidence and risk of cardiovascular diseases or mortality in uncontrolled HT or DM in the Asian population. Epidemiological studies of cardiovascular disease should be conducted with continuous consideration of the changing disease risk profiles, lifestyles, and socioeconomic status over time.

OBJECTIVE

We aimed to examine the association of uncontrolled HT or DM with the incidence of cardiovascular events or deaths from any cause.

METHODS

This population-based retrospective study was conducted using data from the Korean National Health Insurance Service-National Health Screening Cohort, including patients aged 40-79 years who participated in national screening from 2002 to 2003 and were followed up until 2015. The health screening period from 2002 to 2013 was stratified into 6 index periods in 2-year cycles, and the follow-up period from 2004 to 2015 was stratified accordingly into 6 subsequent 2-year periods. The incidence rates and hazard ratio (HR) for major adverse cardiovascular events (MACE) and death from any cause were estimated according to HT or DM control status. Extended Cox models with time-dependent variables updated every 2 years, including sociodemographic characteristics, blood pressure (BP), fasting blood glucose (FBG), medication prescription, and adherence, were used.

RESULTS

Among the total cohort of 440,249 patients, 155,765 (35.38%) were in the uncontrolled HT or DM group. More than 60% of the patients with HT or DM who were prescribed medications did not achieve the target BP or FBG. The incidence of MACE was 10.8-15.5 and 9.6-13.3 per 1000 person-years in the uncontrolled DM and uncontrolled HT groups, respectively, and increased with age. In the uncontrolled HT and DM group, the incidence of MACE was high (15.2-17.5 per 1000 person-years) at a relatively young age and showed no age-related trend. Adjusted HR for MACE were 1.28 (95% CI 1.23-1.32) for the uncontrolled DM group, 1.32 (95% CI 1.29-1.35) for the uncontrolled HT group, and 1.54 (95% CI 1.47-1.60) for the uncontrolled HT and DM group. Adjusted HR for death from any cause were 1.05 (95% CI 1.01-1.10) for the uncontrolled DM group, 1.13 (95% CI 1.10-1.16) for the uncontrolled HT group, and 1.17 (95% CI 1.12-1.23) for the uncontrolled HT and DM group.

CONCLUSIONS

This up-to-date evidence of cardiovascular epidemiology in South Korea serves as the basis for planning public health policies to prevent cardiovascular diseases. The high uncontrolled rates of HT or DM, regardless of medication prescription, have led us to suggest the need for a novel system for effective BP or glycemic control, such as a community-wide management program using mobile health technology.

Temporal Change in the Use of Laboratory and Imaging Tests in One Week Before Death, 2006–2015

BACKGROUND

To analyze the trends in laboratory and imaging test use 1 week before death among decedents who died in Korean hospitals, tests used per decedents from 2006 to 2015 were examined by using the National Health Insurance Service-Elderly Sample Cohort (NHIS-ESC) dataset.

METHODS

The study population consisted of decedents aged ≥ 60 years old with a history of admission and death at a hospital, and tests recorded in the payment claims for laboratory and imaging tests according to the Healthcare Common Procedure Coding System codes were examined. Twenty-eight laboratory and 6 imaging tests were selected. For each year, crude rates of test use per decedents in each age and sex stratum were calculated. Regression analysis was used to examine the temporal changes in the test use.

RESULTS

During the follow-up period, 6,638 subjects included in the sample cohort died. The number of total laboratory and imaging tests performed on the deceased increased steadily throughout the study year from 10.3 tests/deceased in 2006 to 16.6 tests/deceased in 2015. The use of tests increased significantly in general hospitals, however, not in nursing hospitals. Laboratory tests showed yearly increase, from 9.46/deceased in 2006 to 15.57/deceased in 2015, an annual increase of 7.39%. On the other hand, the use of imaging increased from 0.86/deceased in 2006 to 1.01/deceased in 2015, which was not statistically significant.

CONCLUSION

The use of tests, especially laboratory tests, increased steadily over the years even among those elderly patients at imminent death. Reducing acute healthcare at the end of life would be one target not only to support the sustainability of the health care budget but also to improve the quality of dying and death.

Effects of Endocrine Therapy on Cardiovascular Diseases and Type 2 Diabetes Among Breast Cancer Survivors: The National Health Insurance Service Database of Korea

Background Although endocrine therapy is an effective treatment for breast cancer, its antiestrogen effects are associated with increased risks of cardiovascular diseases and type 2 diabetes. This study aimed to investigate the association between endocrine therapy and the risk of cardiovascular diseases and type 2 diabetes among breast cancer survivors in Korea, in consideration of various age groups. Methods and Results In the National Health Insurance Service database of Korea, a total of 133 171 patients with breast cancer aged ≥20 years were included in the current study. Endocrine therapy was treated as time-varying exposure, and patients were categorized as nonusers, selective estrogen receptor modulator users, aromatase inhibitor users, and both users. Time-dependent Cox regression models were used to estimate hazard ratios (HRs) and 95% CIs. Age at diagnosis, socioeconomic status, histological type, other treatments, and comorbidities were adjusted in the model. Compared with nonusers, selective estrogen receptor modulator users were associated with higher risks of stroke (HR, 1.20 [95% CI, 1.04-1.40]) and venous thromboembolism (HR, 1.47 [95% CI, 1.13-1.90]), whereas aromatase inhibitor users were associated with a higher risk of coronary heart disease (HR, 1.22 [95% CI, 1.06-1.41]). The risk of type 2 diabetes was associated with selective estrogen receptor modulator users (HR, 1.13 [95% CI, 1.05-1.21]), aromatase inhibitor users (HR, 1.14 [95% CI, 1.05-1.23]), and both users (HR, 1.24 [95% CI, 1.10-1.39]). In particular, the risk of a composite of cardiovascular diseases was higher in younger or premenopausal patients. Conclusions In breast cancer survivors in Korea, endocrine therapy is associated with a higher risk of cardiovascular diseases and type 2 diabetes. Monitoring of cancer comorbidities after endocrine therapy is needed in younger and older patients.

Clinical and economic impact of changing reimbursement criteria for statin treatment among patients with type 2 diabetes mellitus in South Korea

Aim: Patients with type 2 diabetes mellitus (T2DM) in South Korea can be reimbursed for statins if they have a low-density lipoprotein cholesterol (LDL-C) level of ≥100 mg/dL. We aimed to explore the clinical and economic benefit received by T2DM patients when easing the current criteria for statin treatment by lowering the LDL-C threshold from 100 mg/dL to 70 mg/dL.

Methods: We used a static course model with a 5-year period to compare the following two scenarios in T2DM patients with no history of cardiovascular (CV) events: the current criteria covering LDL-C ≥100 mg/dL and the revised criteria covering LDL-C ≥70 mg/dL. The number of target patients was estimated based on previous Korean studies on patients with T2DM. The current mix of treatments used for T2DM and costs involving CV events were estimated using the National Health Insurance Service–National Health Screening Cohort database. The baseline CV event rates and case fatality were estimated using NHIS Customized database, including 50% patients who were prescribed atorvastatin and 100% who were not prescribed statins between 2009 and 2012 among patients with T2DM in the entire Korean population. After propensity score matching, patients with T2DM not prescribed statins were followed up until 2018 to estimate the incidence rates of coronary heart disease (CHD) and stroke. The efficacy of atorvastatin for the primary prevention of CV events in patients with T2DM was derived from a pivotal clinical trial. The outcome measures were the number of CV events prevented after the change in criteria and the consequent cost savings.

Results: In South Korea, the current and revised criteria covered 2,434,379 and 3,446,149 patients with T2DM, respectively. The change in criteria resulted in the prevention of 726 CV events and cost savings of US dollars (USD) 5.5 million at the national level and USD 0.0089 per member per month in the fifth year.

Conclusion: Easing the reimbursement criteria for statin treatment among patients with T2DM was associated with a reduction in CV events and their related costs; therefore, changing the reimbursement criteria is worth further consideration to mitigate the burden of CV disease.

Association between Retinal Vein Occlusion and Psoriasis in Korea: A Nationwide Population-based Prospective Cohort Study

Psoriasis is a chronic inflammatory skin disease imparting increased risk of cardiovascular diseases. Until now, few studies have reported an increased incidence of ophthalmological retinal vasculopathy in individuals with psoriasis. This study aimed to investigate the association between psoriasis and retinal vein occlusion in the Korean population. Data collected by the National Health Insurance Service between 2009 and 2015 in Korea were analysed. Participants who underwent national health examinations from 2009 to 2012 were enrolled in this study and were divided into either the psoriasis group (n = 3,088) or the control group (n = 465,205). All occurrences of retinal vein occlusion were observed, and the incidence rate of retinal vein occlusion was compared between the psoriasis and control groups. A Cox proportional hazards regression analysis was used to assess the association between psoriasis and newly developed retinal vein occlusion. During a mean 4.37-year follow-up period, 2,034 patients developed retinal vein occlusion. According to multivariable Cox proportional hazard models, individuals with psoriasis had a significantly higher risk of retinal vein occlusion compared with controls (hazard ratio 1.72, 95% confidence interval 1.18–2.51) after adjustments for covariates. This study found that psoriasis was positively associated with retinal vein occlusion.

Association between Retinal Vein Occlusion and Psoriasis in Korea: A Nationwide Population-based Prospective Cohort Study

Psoriasis is a chronic inflammatory skin disease imparting increased risk of cardiovascular diseases. Until now, few studies have reported an increased incidence of ophthalmological retinal vasculopathy in individuals with psoriasis. This study aimed to investigate the association between psoriasis and retinal vein occlusion in the Korean population. Data collected by the National Health Insurance Service between 2009 and 2015 in Korea were analysed. Participants who underwent national health examinations from 2009 to 2012 were enrolled in this study and were divided into either the psoriasis group (n = 3,088) or the control group (n = 465,205). All occurrences of retinal vein occlusion were observed, and the incidence rate of retinal vein occlusion was compared between the psoriasis and control groups. A Cox proportional hazards regression analysis was used to assess the association between psoriasis and newly developed retinal vein occlusion. During a mean 4.37-year follow-up period, 2,034 patients developed retinal vein occlusion. According to multivariable Cox proportional hazard models, individuals with psoriasis had a significantly higher risk of retinal vein occlusion compared with controls (hazard ratio 1.72, 95% confidence interval 1.18-2.51) after adjustments for covariates. This study found that psoriasis was positively associated with retinal vein occlusion.

Multiple metabolic comorbidities and their consequences among patients with peripheral arterial disease

Older adults with peripheral arterial disease (PAD) have increased risks of major cardiovascular events and hospitalization. Metabolic comorbidities, such as hypertension, diabetes mellitus, and dyslipidemia, are common risk factors for these unfavorable health events. This study aimed to determine how multiple metabolic comorbidities affect the risk of adverse health outcomes in older adults with PAD. A retrospective cohort study was adopted using administrative claim data from the Health Insurance Review and Assessment Service Agency. The study sample included 3,122 older adults (≥ 65 years old) with at least one PAD diagnosis in an inpatient setting from 2011 to 2013 and who had at least one follow-up visit after hospitalization by 2018. The three metabolic comorbidities were defined as having at least two diagnostic claims or one prescription per year of anti-hypertensive, anti-diabetic, or anti-dyslipidemic medications for the corresponding diagnosis. The outcome variables included major adverse cardiovascular events (MACEs) and major adverse limb events (MALE). Kaplan-Meier survival curves demonstrated that PAD patients with more metabolic comorbidities had shorter MACE-free and MALE-free periods. Adjusted Cox proportional hazards analyses suggested significant additive effects of multiple metabolic comorbidities on increased risks of MACE and MALE among older adults with PAD. Lower socioeconomic status and non-metabolic comorbidities also increased the risk of MACE. Male sex, being young-old (65–74 years), and a higher proportion of inpatient claims increased the risk of MALE. The findings of this study suggest the need for a comprehensive care program for older adults with PAD and metabolic comorbidities. In addition, the healthcare utilization pattern should be considered when designing preventive care for older patients with comorbidities to manage PAD at an earlier stage.

Budget Impact Analysis of Pharmacist-Led Medication Management in Cardiovascular and Type 2 Diabetic Patients

The paper aims to identify and measure the costs and savings associated with the delivery of Comprehensive Medication Management (CMM) services in Croatia in patients diagnosed with hypertension accompanied by at least one additional established cardiovascular disease (CVD) and/or type 2 diabetes mellitus (DMT2) who use five or more medicines daily. The budget impact analysis (BIA) employed in this study compares the total costs of CMM to the cost reductions expected from CMM. The cost reductions (or savings) are based on the reduced incidence of unwanted clinical events and healthcare service utilisation rates due to CMM. The BIA model is populated by data on medication therapy costs, labour, and training from the pilot CMM intervention introduced in Zagreb’s main Health Centre, while relevant international published sources were used to estimate the utilisation, incidence, and unwanted clinical events rates. Total direct costs, including pharmacists’ labour and training (EUR 2,667,098) and the increase in the cost of prescribed medication (EUR 5,182,864) amounted to EUR 7,849,962 for 3 years, rendering the cost per treated patient per year EUR 57. CMM is expected to reduce the utilisation rates of healthcare services and the incidence of unwanted clinical events, leading to a total 3-year reduction in healthcare costs of EUR 7,787,765. Given the total CMM costs of EUR 7,849,962, CMM’s 3-year budget impact equals EUR 92,869, rendering per treated patient an incremental cost of CMM EUR 0.67. Hence, CMM appears to be an affordable intervention for addressing medication mismanagement and irrational drug use.

Prevalence of Impaired Fasting Glucose and Type 2 Diabetes in Kazakhstan: Findings From Large Study

Type 2 diabetes mellitus (T2DM) is a serious public health problem. A large proportion of patients with T2DM are unaware of their condition. People with undiagnosed T2DM are at a greater risk of developing complications, whereas prediabetes has an elevated risk of becoming T2DM. The aim of this study is to estimate the prevalence of impaired fasting glucose (IFG), undiagnosed and prior-diagnosed T2DM in Kazakhstan. A cross-sectional study was conducted in four geographically remote regions using the WHO STEP survey instrument. The status of T2DM of 4,753 participants was determined using the WHO diagnostic criteria based on fasting plasma glucose (FPG) level. As a result, the survey-weighted prevalence of IFG was 1.9% (95% CI 1.1%; 3.5%) and of T2DM was 8.0% (95% CI 3.8; 15.9). A total of 54% of T2DM have been newly diagnosed with T2DM. Being 55–64 years old (OR = 2.71, 95% CI 1.12; 6.60) and having lowered HDL-C level (OR = 3.72, 95% CI 1.68; 8.23) were found to be independent predictors for IFG. Being older than 45 years, a female (OR = 0.57, 95% CI 0.39; 0.83), having high waist circumference, was associated with newly diagnosed T2DM. Whereas, the age older than 45 years, high waist circumference, and family history of diabetes (OR = 2.42, 95% CI 1.64; 3.54) were associated with preexisting T2DM. This study shows a high prevalence of IFG and a high proportion of newly diagnosed T2DM in Kazakhstan. A series of risk factors identified in the study may be used to strengthen appropriate identification of IFG or undiagnosed patients in healthcare settings to deliver either preventive or therapeutic interventions aimed to reduce the incidence of T2DM or the delay of their complications. Further longitudinal studies are needed to confirm these associations in our population.

Contribution of hypertriglyceridemia to ischemic cardiovascular disease in Korean Women: A nationwide population-based study

BACKGROUND

The independent effect of serum triglyceride levels on the development of ischemic cardiovascular disease (CVD) remains inconclusive, which might be due to heterogeneity among study populations.

OBJECTIVE

To evaluate the effect of triglyceride levels on ischemic CVD and mortality in Korean women, with stratification according to the menopausal status, diabetes mellitus, or low-density lipoprotein cholesterol levels (LDL-C).

METHODS

We retrospectively investigated Korean women aged 40-69 years who underwent health examination in 2009 and were followed up until 2018 using nationwide claim data. The subjects were divided according to triglyceride quartiles (Q): Q1 <70 mg/dL, Q2 71-99 mg/dL, Q3 100-142 mg/dL, and Q4 ≥143 mg/dL. The primary outcome was the incidence of CVD defined as a composite of myocardial infarction and ischemic stroke.

RESULTS

Among 2,208,347 women, primary outcome occurred in 62,255 (2.8%) subjects. As triglyceride levels increased, the event rate of primary outcome increased in both premenopausal and postmenopausal women in the fully adjusted model (hazard ratio [HR] per 1 Q, 1.10 [95% confidence interval (CI), 1.08-1.12] and 1.08 [95% CI, 1.07-1.09], respectively), which was maintained on further stratification according to diabetes or LDL-C (P<0.05 in all). Higher triglyceride levels were more significantly associated with the primary outcome, MI, and stroke risk among women with optimal non-high-density lipoprotein cholesterol levels (non-HDL-C) <130 mg/dL, but only weakly with stroke for women with non-optimal non-HDL-C.

CONCLUSION

Triglyceride is an independent prognosticator in the development of ischemic CVD in Korean women aged 40-69 years.

Positive association between actinic keratosis and internal malignancies: a nationwide population-based cohort study

Little is known about the comorbidities in actinic keratosis patients. To evaluate the association of actinic keratosis with certain malignancies. All patients with actinic keratosis (n = 61,438) and age- and sex-matched control subjects (n = 307,190) at a 5:1 ratio were enrolled using data from the Korean National Health Insurance Service between the years 2007 and 2014. In subjects with actinic keratosis, overall cancer incidence was higher than that for controls after income level, habitat, diabetes, hypertension, and dyslipidemia were adjusted (Hazard Ratio [HR] = 1.43 [95% confidence interval 1.38–1.47]). The positive association of specific cancers were observed in the following order: skin cancer (HR = 3.43 [2.47–4.75]), oral cavity and pharyngeal cancer (HR = 1.99 [1.57–2.52]), lymphoma (HR = 1.59 [1.28–1.96]), leukemia (HR = 1.35 [1.03–1.77]), prostate cancer (HR = 1.35 [1.21–1.51]), renal cancer (HR = 1.29 [1.02–1.63]), liver cancer (HR = 1.21 [1.09–1.35]), thyroid cancer (HR = 1.20 [1.05–1.38]), and gastric cancer (HR = 1.13 [1.03–1.23]). Although further research on pathologic mechanism is needed, the implications of a positive correlation between actinic keratosis and internal organ malignancies has great significance.

Cardiovascular Outcomes of Obesity According to Menopausal Status: A Nationwide Population-Based Study

BACKGROUND

We estimated the effect of obesity on the incidence of cardiovascular disease (CVD) and mortality in women according to menopausal status.

METHODS

Women aged 40 to 69 years under routine health check-ups provided by the National Health Insurance Service in 2009 were followed up till 2018 (n=2,208,559).

RESULTS

In premenopausal women, a significant increment of mortality rate was found in underweight and obesity class II (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.31 to 1.67; and HR, 1.25; 95% CI, 1.12 to 1.39) compared to normal body mass index (BMI); overweight and obesity class I did not affect mortality rate. In postmenopausal women, obesity as well as overweight status reduced the risk of mortality compared to normal BMI (HR, 0.86; 95% CI, 0.83 to 0.88; and HR, 0.84; 95% CI, 0.82 to 0.86). By contrast, there was a linear association between CVD and BMI above the normal range irrespective of menopausal status, which was attenuated in diabetic women.

CONCLUSION

The current study replicated the J-shaped relationship between BMI and mortality, being more prominent in the postmenopausal group. The risk of CVD was linearly increased as BMI was increased above the normal range irrespective of menopausal status.

Effects of menopausal hormone therapy on cardiovascular diseases and type 2 diabetes in middle-aged postmenopausal women: analysis of the Korea National Health Insurance Service Database

OBJECTIVE

Although menopausal hormone therapy (MHT) is the most effective treatment for menopausal symptoms, menopausal women hesitate to start MHT due to concerns about adverse events. Recently, however, it has been recommended to use it for appropriate patients who have been evaluated for baseline diseases, age, and timing of initiation. We aimed to investigate the association of MHT with cardiovascular diseases (CVDs) and type 2 diabetes among middle-aged postmenopausal women in Korea.

METHODS

Data were collected from the National Health Insurance Service database in Korea from 2002 to 2016. A total of 58,060 postmenopausal women (including 8,013 [13.8%] MHT users and 50,047 [86.2%] nonusers) were included. The time-dependent Cox regression model with a 1-year latency period was used to evaluate the hazard ratio (HR) and 95% confidence interval (CI) of the associations of MHT with CVDs and type 2 diabetes outcomes. Subgroup analyses by regimen type and cumulative duration were conducted.

RESULTS

In the multivariate-adjusted model, MHT was not significantly associated with CVDs (HR = 1.085, 95% CI: 0.899-1.310) or type 2 diabetes (HR = 1.104, 95% CI: 0.998-1.221). Differential effects were not observed by regimen type, cumulative duration, and years since menopause subgroups. Sensitivity analyses also did not show adverse events by MHT on CVDs and type 2 diabetes.

CONCLUSIONS

Although protective effects of MHT against CVDs or type 2 diabetes were not observed among postmenopausal women who had screened underlying diseases, our results may contribute to reducing the current concerns about the use of MHT for middle-aged postmenopausal women in Korea.

Update on polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common disorder in reproductive-age women. In 2018, an international evidence-based guideline announced recommendations spanning a wide range of issues on the assessment and management of PCOS. From the 166 recommendations, the present study reviews those that are of particular clinical relevance for daily practice and introduces other relevant studies that have been published since the global guideline. The 2018 guideline increased the antral follicle count cutoff for the diagnosis of PCOS from 12 to 20 when using a high-frequency probe. Hirsutism was defined as having a score of ≥4–6 based on a lower percentile of 85%–90% or cluster analysis, which was lower than the traditionally used 95th percentile-based cutoff. The diagnosis of PCOS in adolescents is challenging, and irregular menstruation was defined carefully according to years from menarche. The use of ultrasonography for the diagnosis of PCOS was restricted to those 8 years after menarche. As medication for non-fertility indications, combined oral contraceptives are the first-line drug. Metformin, in addition to lifestyle modifications, should be considered for adult patients with a body mass index ≥25 kg/m² for the management of weight and metabolic outcomes. An aromatase inhibitor is the recommended first-line medication for ovulation induction, a subsequent individual patient data meta-analysis also reported the same conclusion. Whether the new global guideline will be fully adopted by many specialists and change clinical practice is open to question. Further studies are needed to better understand and manage PCOS patients well.

Trends in prevalence and incidence of type 2 diabetes among adults in Beijing, China, from 2008 to 2017

AIMS

To describe secular trends in diagnosed type 2 diabetes prevalence and incidence in Beijing, China.

METHODS

Using health insurance claims for 17.7 million adults ≥20 years in 2008-2017, we identified people with diabetes using hospital diagnoses and drug prescriptions. Results were age-standardised using data for Beijing from China's 2010 census. Trends in prevalence and incidence were analysed using Joinpoint regression analysis.

RESULTS

From 2008 to 2017, we identified 2,104,159 people diagnosed with type 2 diabetes. Type 2 diabetes prevalence increased from 3.7% [95% CI: (3.6, 3.8)] to 6.6% (6.4, 6.7), but the annual rate of increase slowed from 18.1% (14.4, 22.0) to 1.5% (0.8, 2.2) before and after 2011 respectively. Women had a higher diabetes prevalence than men, for all years. The yearly increase in prevalence was greater in people younger than 40 years, with an average annual percentage change of 13.6% (10.7, 16.5) compared to 6.5% (5.6, 7.4) in those over 40 years. Over the 10 years, the overall incidence decreased from 24.3 (24.2, 24.4) to 11.5 (11.5, 11.6) per 1000 person-years, but it increased in people younger than 40 years. The average age at diabetes diagnosis dropped from 62 to 56 years (p < 0.001). Among incident cases of diabetes, the percentage of people under 40 years increased from 3.0% to 10.9% (p < 0.001).

CONCLUSIONS

The prevalence of diagnosed type 2 diabetes in Beijing increased continuously over the 10 years, the incidence decreased, except in people under 40 years. Continuous efforts are needed to prevent diabetes in China.

Potential intrinsic subtype dependence on the association between metformin use and survival in surgically resected breast cancer: a Korean national population-based study

PURPOSE

Numerous studies have suggested that metformin treatment can increase breast cancer survival; however, it is unclear whether its effects interact with intrinsic subtype or diabetic status. Therefore, we conducted a large nationwide study to assess this in women with surgically resected invasive breast cancer.

METHODS

Patients with newly diagnosed breast cancer between 2007 and 2016 were identified using the national health insurance claims database of South Korea. Metformin or other drug exposures was defined as medication for ≥ 90 days. Breast cancer subtypes were classified into four groups based on hormonal therapy and anti-HER2 treatments.

RESULTS

A total of 117,333 patients were included (median follow-up duration, 90 months). Type 2 diabetes mellitus (T2DM) affected significantly overall survival (OS, 7 years, 89.7% vs. 92.4%, p < 0.001). A significant interaction was found between the use of metformin and insulin in patients with T2DM (p = 0.018). Thus, the subsequent analysis was limited to these patients and propensity score matching was performed. We found significantly increased OS in patients treated with metformin (7-year OS, 88.3% vs. 85.6%, p < 0.001). Interestingly, a significant effect was observed in the hormonal therapy (HT)+/HER2-targeted therapy (Tx)- group (p < 0.001), whereas no specific association was observed in the HT-/HER2 Tx- group (p = 0.220).

CONCLUSIONS

Metformin administration may be associated with reduced mortality in patients with surgically resected breast cancer, particularly in the HT+/HER2 Tx- group. Clinical trials investigating metformin as a combination agent in breast cancer should stratify patients by curative resection, intrinsic subtype, the presence of T2DM, and the use of insulin.

Association between hospital liver transplantation volume and mortality after liver re-transplantation

BACKGROUND

The relationship between institutional liver transplantation (LT) case volume and clinical outcomes after liver re-transplantation is yet to be determined.

METHODS

Patients who underwent liver re-transplantation between 2007 and 2016 were selected from the Korean National Healthcare Insurance Service database. Liver transplant centers were categorized to either high-volume centers (≥ 64 LTs/year) or low-volume centers (< 64 LTs/year) according to the annual LT case volume. In-hospital and long-term mortality after liver re-transplantation were compared.

RESULTS

A total of 258 liver re-transplantations were performed during the study period: 175 liver re-transplantations were performed in 3 high-volume centers and 83 were performed in 21 low-volume centers. In-hospital mortality after liver re-transplantation in high and low-volume centers were 25% and 36% (P = 0.069), respectively. Adjusted in-hospital mortality was not different between low and high-volume centers. Adjusted 1-year mortality was significantly higher in low-volume centers (OR 2.14, 95% CI 1.05-4.37, P = 0.037) compared to high-volume centers. Long-term survival for up to 9 years was also superior in high-volume centers (P = 0.005). Other risk factors of in-hospital mortality and 1-year mortality included female sex and higher Elixhauser comorbidity index.

CONCLUSION

Centers with higher case volume (≥ 64 LTs/year) showed lower in-hospital and overall mortality after liver re-transplantation compared to low-volume centers.

Progression to prediabetes or diabetes in young Korean women with polycystic ovary syndrome: A longitudinal observational study

OBJECTIVE

To investigate changes in glycaemic status in women with polycystic ovary syndrome (PCOS).

DESIGN

Longitudinal observational study.

PATIENTS

Women with PCOS who underwent baseline and follow-up screening tests for diabetes (n = 262). Four patients with type 2 diabetes (T2DM) at baseline and 6 patients who were taking drugs at the final follow-up were excluded.

MEASUREMENTS

Changes in glycaemic classification based on fasting glucose, haemoglobin A1c and oral glucose tolerance test.

RESULTS

The median length of follow-up was 2.9 years. The mean age and body mass index in the normoglycaemia group (n = 202) were 23.0 years and 21.6 kg/m² , while it was 23.6 years and 22.9 kg/m² in the prediabetes group (n = 50). In the normoglycaemia group, 38 (18.8%) and 2 (1.0%) developed prediabetes and T2DM, respectively. In the prediabetes group, 22 (44.0%) remained in the same category, 6 (12.0%) developed T2DM, while 22 (44.0%) achieved normoglycaemia. The incidence rate of T2DM was 9.3 per 1,000 person-years, which was significantly higher than that of the female population of similar age, and the incidence was higher in women with fasting glucose ≥ 5.6 mmol/L at baseline than in women with < 5.6 mmol/L.

CONCLUSIONS

About 20% of normoglycaemic women had developed prediabetes or T2DM after a median time of 2.9 years. Meanwhile, nearly half of prediabetes women achieved normoglycaemia. Higher baseline fasting glucose levels were associated with an increased incidence of T2DM. Our results are the first to evaluate glycaemic status changes using all three parameters in patients with PCOS.

The relationship between metabolic syndrome and obstructive sleep apnea syndrome: a nationwide population-based study

There has been a need for research on the association between metabolic syndrome (MetS) and obstructive sleep apnea syndrome (OSAS) using large data such as nationwide population-based data that adjusts important confounding factors. Therefore, we investigated the relationship between MetS and OSAS. The data source we used was the National Health Insurance Service claims database managed by the Republic of Korea government, in which 10,113,560 individuals were enrolled in 2009 and followed up until 2018. The independent association of MetS with the risk of OSAS was determined using a Cox proportional hazards model with adjustment for age, sex, smoking status, alcohol consumption, regular physical exercise, and body mass index. Our results showed that MetS were strongly associated to OSAS which was adjusted for several confounding factors. Also, we found men, increased waist circumference and increased triglyceride are important risk factors for OSAS.

Hypertriglyceridemia Is an Independent Risk Factor for Cardiovascular Diseases in Korean Adults Aged 30-49 Years: a Nationwide Population-Based Study

Objective

This study was conducted to estimate the incidence of cardiovascular disease (CVD) independently from low-density lipoprotein (LDL) cholesterol according to triglyceride (TG) levels in young adults.

Methods

Subjects aged 30–49 years with data from routine health check-ups provided by the National Health Insurance Service during 2009 were selected. The primary outcome was incident CVD, defined as a composite of ischemic heart disease and ischemic stroke during the follow-up period from 2009 to 2018.

Results

The mean age of study subjects (n=1,823,537) was 40.1±5.7 years, and the median follow-up period was 8.3 years. The quartiles of serum TG levels at the baseline were calculated: Q1, <74 mg/dL; Q2, 74–108 mg/dL; Q3, 109–166 mg/dL; and Q4: >166 mg/dL. The highest quartile of TG levels (Q4) had a significantly higher risk of the primary outcome than Q1 (hazard ratio [HR], 2.40 [95% confidence interval; CI, 2.33–2.47]). Q2 and Q3 also experienced the primary outcome more frequently than Q1 (HR, 1.37 [95% CI, 1.33–1.42] and HR, 1.80 [95% CI, 1.75–1.86], respectively). Even after adjustment for age, sex, obesity, alcohol drinking amount, smoking, LDL cholesterol, diabetes mellitus, hypertension, lipid-lowering medication use, and family history of CVD, there was a significant dose-response relationship between TG quartiles and the risk of the primary outcome (HR per quartile, 1.13 [95% CI, 1.12–1.14]).

Conclusion

In conclusion, in the Korean population aged 30–49 years, high TG levels independently increased future CVD risk in both men and women.

Direct Medical Costs of Incident Complications in Patients Newly Diagnosed With Type 2 Diabetes in China

INTRODUCTION

Reliable country-specific incidence and cost data on diabetes-related complications are essential inputs for the projections of the economic burden of diabetes. The aim of this study was to provide patient-level cost estimates of managing and treating complications in patients newly diagnosed with type 2 diabetes mellitus (T2DM) in China.

METHODS

Patients newly diagnosed with T2DM in the Tianjin Urban Employee Basic Medical Insurance Claims database between 2008 and 2015 were identified and followed up. The cumulative incidence and descriptive costs of certain macrovascular and microvascular complications were examined. A generalized estimating equations model was used to estimate the immediate- and long-term costs for the incident complication in quarterly intervals, controlling for demographics and the confounding effects of comorbid complications.

RESULTS

A total of 114,847 newly diagnosed patients were identified (mean age 56.9 years, 45.5% women). After 7 years, 80.8% of the patients at risk had developed nephropathy and 75.7% had developed neuropathy. The immediate additional costs were highest for myocardial infarction during the quarterly interval that the complication first occurred (China yuan [CNY] 19,633), and the long-term costs were highest for stroke in the quarterly intervals of subsequent years (CNY 1087). The expected costs for all complications were calculated and presented as costs per quarterly interval and per year for different age and sex subgroups.

CONCLUSIONS

Managing complications results in substantial costs to the Chinese healthcare system. Our study contributes towards quantifying the economic burden and supports the parametrization of economic models of diabetes in China.

The Liability Threshold Model for Predicting the Risk of Cardiovascular Disease in Patients with Type 2 Diabetes: A Multi-Cohort Study of Korean Adults

Personalized risk prediction for diabetic cardiovascular disease (DCVD) is at the core of precision medicine in type 2 diabetes (T2D). We first identified three marker sets consisting of 15, 47, and 231 tagging single nucleotide polymorphisms (tSNPs) associated with DCVD using a linear mixed model in 2378 T2D patients obtained from four population-based Korean cohorts. Using the genetic variants with even modest effects on phenotypic variance, we observed improved risk stratification accuracy beyond traditional risk factors (AUC, 0.63 to 0.97). With a cutoff point of 0.21, the discrete genetic liability threshold model consisting of 231 SNPs (GLT₂₃₁) correctly classified 87.7% of 2378 T2D patients as high or low risk of DCVD. For the same set of SNP markers, the GLT and polygenic risk score (PRS) models showed similar predictive performance, and we observed consistency between the GLT and PRS models in that the model based on a larger number of SNP markers showed much-improved predictability. In silico gene expression analysis, additional information was provided on the functional role of the genes identified in this study. In particular, HDAC4, CDKN2B, CELSR2, and MRAS appear to be major hubs in the functional gene network for DCVD. The proposed risk prediction approach based on the liability threshold model may help identify T2D patients at high CVD risk in East Asian populations with further external validations.

Assessment of asthma severity according to treatment steps in Japanese pediatric patients: a descriptive cross-sectional study using an administrative claims database

OBJECTIVES

Japan has one of the highest asthma prevalence rates in Asia; however, there is a lack of epidemiological studies on asthma among children in Japan. This study aimed to describe the severity of asthma and the prescription patterns for its treatment among pediatric patients, by using a large-scale claims database.

METHODS

The analysis datasets were extracted from the JMDC database for the period of April 1, 2009 to March 30, 2015; included records were restricted to patients between 2 and 15 years of age. The Japanese Pediatric Guidelines for the treatment and management of asthma (JPGL) steps were used as a proxy for asthma treatment and severity. We also described the characteristics of asthma in children by stratifying the prevalence and incidence cohorts by index years.

RESULTS

In the prevalence cohort (56% male), from 2010 to 2014, approximately 80-90% of the children received step 1 or 2 treatment, with the remainder receiving step 3 or 4 treatment, as defined by the JPGL. The majority (approximately 90%) of patients visited clinics for asthma treatment, while a minority visited hospitals.

CONCLUSIONS

Our study showed the severity of asthma among Japanese pediatric patients, as well as their demographic characteristics, using a large-scale claims database. The majority of pediatric asthma patients received treatment for mild-to-moderate asthma, while less than 10% received treatment for severe asthma.

Incidence and Outcomes of Sepsis in Korea: A Nationwide Cohort Study From 2007 to 2016

OBJECTIVES

This study aimed to estimate the incidence and clinical outcomes of sepsis in Korea from 2007 to 2016.

DESIGN

Retrospective observational study.

SETTING

Nationwide study with population-based healthcare reimbursement claims database.

PATIENTS

Using data from the National Health Insurance Service of Korea, patients who were hospitalized with a diagnosis of sepsis from 2007 to 2016 were analyzed. The incidence of sepsis was calculated using mid-year census population and analyzed according to year, age, and sex. The Elixhauser Comorbidity Index score was calculated to adjust for the impact of comorbidities on clinical outcome. In-hospital mortality, hospital length of stay, ICU admission rates, and risk factors for in-hospital mortality were also analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The incidence of sepsis increased from 173.8 per 100,000 population in 2007 to 233.6 per 100,000 population in 2016. In-hospital mortality decreased from 30.9% in 2007 to 22.6% in 2016 (p < 0.0001). From 2007 to 2016, hospital length of stay and ICU admission rates associated with sepsis decreased from 26.0 ± 33.5 days to 21.3 ± 24.4 days (p < 0.0001) and from 16.2% to 12.7% (p < 0.0001), respectively. Male sex, age greater than 50 years, Elixhauser Comorbidity Index greater than 10, and mechanical ventilation were identified as risk factors for in-hospital mortality after adjusting for baseline characteristics.

CONCLUSIONS

The incidence of sepsis in Korea increased from 2007 to 2016, while the associated in-hospital mortality, hospital length of stay, and ICU admission rates decreased.

Incidence of Severe Chronic Neutropenia in South Korea and Related Clinical Manifestations: A National Health Insurance Database Study

Background and objectives: Severe chronic neutropenia (SCN) is a condition in which absolute neutrophil counts remain at a low level (under 500/µL) over months or years. Because of the rare onset of SCN, its epidemiology, prognosis, and clinical manifestations have not yet been fully understood. In particular, large-cohort studies in Asian countries are still insufficient. Therefore, in this study, national health insurance data was used to investigate the epidemiologic features and prognosis of SCN in South Korea. Materials and Methods: The data from the Health Insurance Review and Assessment database recorded between 1 January 2011 and 31 December 2015 were explored. SCN was defined based on the ICD-10 code, registry of benefit extension policy, and inclusion criteria of the study. After identifying patients with SCN, annual incidence and their co-morbidities were analyzed. Results: Among the initially identified patients with severe neutropenia (N = 2145), a total of 367 patients had SCN and were enrolled. The annual incidence rate of SCN ranged from 0.12 to 0.17 per 100,000 person-year (PY) during the study period. The highest incidence was observed in pediatric patients aged between 0 to 9 years (N = 156), followed by women in their fifties (N = 43). The total incidence rate was 0.17 in females and 0.12 in males (Relative risk (RR): 1.43, 95%, CI: 1.16–1.76). The most common accompanying condition was mild respiratory infection, but about 3.2% of patients progressed to hematologic malignancy after an average of 2.4 years. Conclusions: This nationwide population-based epidemiological study showed that incidence of SCN is higher in pediatrics and middle-aged women. As progression to hematologic malignancy was significantly higher in the age of in 45–49 years old, careful follow-up is necessary in this group. However, since this study lacks the molecular information, these finding need to be interpreted with great caution.

Contemporary use of lipid-lowering therapy for secondary prevention in Korean patients with atherosclerotic cardiovascular diseases

BACKGROUND/AIMS

We evaluated the contemporary use of lipid-lowering therapy (LLT) in Korean patients with atherosclerotic cardiovascular disease (ASCVD), and identified factors associated with statin non-prescription.

METHODS

Using the Korean Health Insurance Review and Assessment data, we identified LLT-naïve subjects newly diagnosed with ASCVD between 2011 and 2012, and followed up until 2015. LLT-naïve status was defined as no LLT prescription for 1 year before ASCVD diagnosis. ASCVD was defined as first hospitalization or emergency room visit for coronary artery disease (CAD), acute cerebrovascular disease (CVD), or peripheral artery disease (PAD). Statin intensity was defined per the 2013 American College of Cardiology/American Heart Association guideline for cholesterol treatment.

RESULTS

The study enrolled 80,884 subjects newly diagnosed with ASCVD, of whom only 48,725 (60.2%) received LLT during the follow-up period. Statin, combination of statin and non-statin, and non-statin LLT were administered in 50.5%, 9.7%, and 0.1% of all subjects, respectively. Statins were prescribed to 80.4% of CAD patients but only to 50.2% and 46.8% of CVD and PAD patients. Statin-based LLT usually had moderate- (77.2%) or high-intensity (18.5%). Subjects not prescribed statins were younger or older (< 40 or ≥ 70 years), more commonly female, and more likely to have comorbidities. Statins were prescribed at the time of ASCVD diagnosis in 45.5% of all subjects, and in 53.0% within 90 days of diagnosis.

CONCLUSION

Only 60% of LLT-naïve Korean patients newly diagnosed with ASCVD received statins. Statins were often prescribed in subjects with CAD but less commonly in those with CVD or PAD. Moderate-intensity statins were most frequently used.

Long-Term Treatment Outcomes in Type 3 Neovascularization: Focus on the Difference in Outcomes between Geographic Atrophy and Fibrotic Scarring

Background: To evaluate the difference in the long-term treatment outcomes of type 3 neovascularization between eyes with geographic atrophy and those with fibrotic scars. Methods: This retrospective study included 195 eyes diagnosed with type 3 neovascularization and treated with anti-vascular endothelial growth factor (VEGF) agents. The included eyes were divided into three groups according to the fundus findings at the final visit: patients with fovea-involving geographic atrophy (GA group), patients with fovea-involving fibrotic scars (scar group), and patients with no fovea-involving geographic atrophy or fibrotic scars (non-GA/scar group). The best-corrected visual acuities (BCVA) of the three groups at the final visits were compared. Results: The mean follow-up period was 47.5 ± 20.7 months. The mean logMAR BCVA at the final visit was 1.18 ± 0.58 in the GA group (n = 58), 1.67 ± 0.58 in the scar group (n = 62), and 0.69 ± 0.64 in the non-GA/scar group (n = 75). The BCVA was significantly worse in the scar group than in the GA (p < 0.001) and the non-GA/scar groups (p < 0.001). Conclusion: Eyes with fibrotic scars showed the poorest visual outcomes in type 3 neovascularization among the studied groups. Preventing the development of fibrotic scars should be considered an important treatment goal.

Increased risk of Alzheimer's disease in patients with psoriasis: a nationwide population-based cohort study

Although the pathogenesis of Alzheimer’s disease (AD) is unclear, neuroinflammation appears to play a role in its development. Psoriasis is a chronic inflammatory skin disease that has recently been found to genetically overlap with AD. We aimed to investigate the risk of AD in patients with psoriasis. Subjects with psoriasis (n = 535,927) and age- and sex-matched controls without psoriasis (at a 5:1 ratio; n = 2,679,635) who underwent ≥3 health examinations between 2008 and 2014 were included, drawn from the Korean National Health Insurance System database. There were 50,209 cases of AD (1.87%) in controls without psoriasis and 11,311 cases (2.11%) in patients with psoriasis, and the median follow-up was 3.35 years. In a multivariable-adjusted model, patients with psoriasis showed a significantly increased risk of AD (hazard ratio, 1.09; 95% CI, 1.07–1.12, p < 0.0001) compared to controls without psoriasis. Among patients with psoriasis, the risk of AD was significantly increased in psoriasis patients not receiving systemic therapy compared to those receiving systemic therapy (hazard ratio, 1.10; 95% CI, 1.08–1.12 vs. hazard ratio, 0.99; 95% CI: 0.90–1.09, p < 0.0001). The incidence of AD was significantly increased in patients with psoriasis compared to control subjects without psoriasis. Of note, systemic treatment for psoriasis was associated with a reduced risk of AD.

Development of stroke identification algorithm for claims data using the multicenter stroke registry database

BACKGROUND

Identifying acute ischemic stroke (AIS) among potential stroke cases is crucial for stroke research based on claims data. However, the accuracy of using the diagnostic codes of the International Classification of Diseases 10th revision was less than expected.

METHODS

From the National Health Insurance Service (NHIS) claims data, stroke cases admitted to the hospitals participating in the multicenter stroke registry (Clinical Research Collaboration for Stroke in Korea, CRCS-K) during the study period with principal or additional diagnosis codes of I60-I64 on the 10th revision of International Classification of Diseases were extracted. The datasets were randomly divided into development and validation sets with a ratio of 7:3. A stroke identification algorithm using the claims data was developed and validated through the linkage between the extracted datasets and the registry database.

RESULTS

Altogether, 40,443 potential cases were extracted from the NHIS claims data, of which 31.7% were certified as AIS through linkage with the CRCS-K database. We selected 17 key identifiers from the claims data and developed 37 conditions through combinations of those key identifiers. The key identifiers comprised brain CT, MRI, use of tissue plasminogen activator, endovascular treatment, carotid endarterectomy or stenting, antithrombotics, anticoagulants, etc. The sensitivity, specificity, and diagnostic accuracy of the algorithm were 81.2%, 82.9%, and 82.4% in the development set, and 80.2%, 82.0%, and 81.4% in the validation set, respectively.

CONCLUSIONS

Our stroke identification algorithm may be useful to grasp stroke burden in Korea. However, further efforts to refine the algorithm are necessary.

Incidence and Time Trends of Type 2 Diabetes Mellitus among Adults in Zhejiang Province, China, 2007-2017

AIMS

Population-based incidence data are paramount to assess the effects of prevention strategies for diabetes, yet the relevant studies in mainland China are scarce. This study is aimed at estimating the type 2 diabetes mellitus (T2DM) incidence and time trends in Chinese adults. Material and Methods. Based on the Diabetes Surveillance System of Zhejiang Province, 879,769 newly diagnosed T2DM cases were identified from January 1, 2007, to December 31, 2017. Annual incidence, incidence rate ratios (IRRs), and average annual percentage change with their 95% confidence intervals (CIs) were reported.

RESULTS

The age-standardized overall incidence rate of T2DM was reported to be 281.73 (95% CI: 281.26-282.20) per 100,000 person-years, 293.19 (95% CI: 292.51-293.87) in males and 270.42 (95% CI: 269.76-271.09) in females. Compared with the ≥80 years age group, younger adults were at lower risk for T2DM (IRRs ranged from 0.035 to 0.986 and the 95% CIs did not include the null), except for the 70-79 years age group (IRR: 1.087, 95% CI: 1.077-1.097). Compared with females and rural areas, the risk for T2DM was higher in males (IRR: 1.083, 95% CI: 1.079-1.088) and urban areas (IRR: 1.005, 95% CI: 1.001-1.009), respectively. The standardized annual incidence rate increased from 164.85 in 2007 to 268.65 per 100,000 person-years in 2017, with an average annual increase of 4.01% and grew more rapidly in male, younger, and rural area populations.

CONCLUSIONS

Our study suggested a significant increase in the incidence rate of T2DM among Chinese over the past decade, especially in adults characterized by male sex, younger age, and rural areas.

A simple screening score to predict diabetes in cancer patients: A Korean nationwide population-based cohort study

Many cancer patients develop diabetes, which may result in reduction of chemotherapy effectiveness and increased infection risk and cardiovascular mortality. Diabetes may also increase the risks of chemotherapy-related toxicity and post-operative mortality, or represent an obstacle to optimal cancer treatment. However, the clinical predictors of diabetes in cancer patients remain largely unknown. Therefore, the aim of our study was to evaluate the risk factors for developing diabetes and construct a nomogram to predict diabetes in cancer patients.We investigated patients from a national sample cohort obtained from the Korea National Health Insurance Service (KNHIS), which included 2% of the Korean population. Patients who had undergone routine medical evaluation by the KNHIS between 2004 and 2008 and been hospitalized due to cancer (ICD-10 codes C00-97) during the past 3 years were included. After excluding patients with type 2 diabetes and missing data, 10,899 patients were enrolled and followed-up until 2013. A total of 7630 (70%) patients were assigned as the training cohort and used to construct the nomogram which was based on a multivariable logistic regression model. The remaining patients (n = 3269) were used as the validation cohort.The incidence rate of diabetes was 12.1 per 1000 person-years over a mean follow-up of 6.6 ± 1.8 years. Significant risk factors for developing diabetes were age, sex, obesity, fasting plasma glucose, hypertension, and hypercholesterolmia. A nomogram was constructed using these variables and internally validated. The area under the curve was 0.70 (95% confidence interval, .666-.730, P < .0001) and the calibration plot showed agreement between the actual and nomogram-predicted diabetes probabilities.The nomogram developed in this study is easy to use and convenient for identifying cancer patients at high-risk for type 2 diabetes, enabling early type 2 diabetes screening and management.

Prevalence of undiagnosed diabetes mellitus and associated factors among adult residents of Bahir Dar city, northwest Ethiopia: a community-based cross-sectional study

OBJECTIVE

To assess the prevalence of undiagnosed diabetes mellitus (DM) and associated factors among adult inhabitants of Bahir Dar city, northwest Ethiopia.

DESIGN

A community-based cross-sectional study was conducted on adults (n=607) of Bahir Dar city from 10 March to 20 May 2018.

MEASUREMENTS

Data were collected using structured interviewer-administered questionnaire, and anthropometric measurements were taken from each participant. Fasting blood sugar (FBS) level was determined by samples taken early in the morning and readings of FBS≥126 mg/dL were classified as diabetes. The multivariate logistic regression model was fitted to identify the predictors of undiagnosed DM; adjusted OR (AOR) with a 95% CI was computed to assess the strength of associations.

RESULT

The study revealed that the prevalence of undiagnosed DM was 10.2% with 95% CI 7.9 to 12.9. Ever checked blood glucose level (AOR=1.91, 95% CI 1.03 to 3.51), don't know the symptoms of diabetes (AOR=2.06, 95% CI 1.08 to 3.89), family history of DM (AOR=2.5, 95% CI 1.21 to 5.18) and body mass index (BMI) ≥25 kg/m² (AOR=1.98, 95% CI 1.09 to 3.60) were factors associated with undiagnosed DM.

CONCLUSION

The magnitude of undiagnosed diabetes was high. Family history of DM, ever checked blood glucose level, don't know about the symptoms of diabetes and overweight BMI were predictors of undiagnosed DM. Hence, screening and treatment are mandatory for high-risk groups. In addition, this study suggests frequent screening for those with family history and awareness creating about the disease for early detection and treatment.

Atorvastatin Induces Hepatotoxicity in Diabetic Rats via Oxidative Stress, Inflammation, and Anti-Apoptotic Pathway

Background

Patients with diabetes mellitus (DM) commonly receive statins to suppress vulnerability to adverse cardiovascular events. It has been clinically proven that hepatotoxicity is one of the most severe adverse effects of statins.

Material/Methods

We constructed diabetic rat models by feeding rats with high-fat food and by injection of low-dose STZ. Rats were randomized into 2 groups: a DM group (n=10) and a control (CON) group (n=5). CON rats received a normal diet, whereas DM rats ate high-fat food. Rats in the DM group underwent intraperitoneal STZ (35 mg/kg) injection following 6-week diet restriction. On the seventh day following STZ or blank injection, rats with FBG concentration over 11.1 mM were regarded as successfully established models and were used for further research.

Results

We showed that severe liver injury occurred in diabetic rats treated with 20 mg/kg atorvastatin, as evidenced by attenuation of liver enzyme activities, elevation of bilirubin levels, and alterations in the hepatic architecture, including hepatocyte death by necrosis, lymphocyte infiltration, and fibrosis. We also found that atorvastatin increased the secretion of pro-inflammatory factors such as L-1, TNF, IL-6, and IL-18 by enhancing activation of the NF-B signal pathway in the livers of diabetic rats. Atorvastatin elevated the levels of ROS and reduced the antioxidant enzyme (SOD and CAT) activities. Atorvastatin also increased the expression of anti-apoptotic protein BCL2 and decreased the expression of pro-apoptotic protein BAX in the livers of diabetic rats.

Conclusion

Atorvastatin exerts potentially hepatotoxic effects on diabetic rats by modulating oxidative/antioxidative status, pro-inflammatory cytokine production, and apoptosis inhibition.

The incidence rates and risk factors of Parkinson disease in patients with psoriasis: A nationwide population-based cohort study

BACKGROUND

The association between psoriasis and Parkinson disease has not been established.

OBJECTIVE

To determine the incidence rates and risk factors of Parkinson disease in patients with psoriasis.

METHODS

We conducted a nationwide population-based cohort study. The data from patients with psoriasis (N = 548,327, ≥20 years of age, 53.32% men and 46.68% women) and age- and sex-matched control patients (N = 2,741,635) without psoriasis were analyzed in this study.

RESULTS

The incidence rates of Parkinson disease per 1000 person-years were 0.673 and 0.768 in the control and psoriasis groups, respectively. The psoriasis group showed a significantly increased risk of developing Parkinson disease (hazard ratio [HR] 1.091, 95% confidence interval [CI] 1.029-1.115). The risk of Parkinson disease was significantly higher among the psoriasis patients who were not receiving systemic therapy (HR 1.093, 95% CI 1.031-1.159) and lower among the psoriasis patients on systemic therapy (HR 1.04, 95% CI 0.806-1.316).

LIMITATIONS

The limitations of this study included the retrospective design, patient inclusion solely on the basis of diagnostic codes, and unavailability of data on confounding factors.

CONCLUSION

Systemic anti-inflammatory agents might mitigate the risk of Parkinson disease in psoriasis patients.

Complementing conventional infectious disease surveillance with national health insurance claims data in the Republic of Korea

Surveillance remains an important tool for timely outbreak detection and response. Many countries, including Korea, have established national infectious disease surveillance systems with clinical notification. We aimed to evaluate the National Health Insurance Claims-based Surveillance (NHICS) compared to conventional passive report-based National Infectious Diseases Surveillance (NIDS). Reported to claimed cases ratios (R/C ratio) were evaluated from monthly notifiable disease cases captured by NIDS and NHICS. The relationships between 26 infectious diseases and each surveillance system were analysed using Pearson’s correlation analysis and linear regression. There was an overall increase in R/C ratio from 2010–2017 (0.37 to 0.78). In 22 infectious diseases, there was a correlation between NIDS and NHICS. Moreover, claim-based surveillance showed less fluctuating disease incidence rates than report-based surveillance for specific infectious diseases, such as varicella, mumps, and scarlet fever. However, for infectious diseases with episodic outbreaks or low incidence, it was difficult to assess NHICS usefulness. Claim-based surveillance is less affected by limitations of conventional report-based surveillance systems, such as reporting rate. Given delays in claim systems, a claim-based surveillance is expected to be complementary to conventional systems for the detection of various infectious diseases with the advancement of bio-information technology.

The Role of Glucagon-Like Peptide 1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors in Reducing Cardiovascular Events in Patients with Type 2 Diabetes

The prevalence of type 2 diabetes mellitus (T2DM), which is associated with cardiovascular morbidity and mortality, is increasing worldwide. Although there have been advances in diabetes treatments that reduce microvascular complications (nephropathy, neuropathy, retinopathy), many clinical studies have found that conventional oral hypoglycemic agents and glucose control alone failed to reduce cardiovascular disease. Thus, incretin-based therapies including glucagon-like peptide 1 (GLP-1) receptor agonists (RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT-2Is) represent a new area of research, and may serve as novel therapeutics for treating hyperglycemia and modifying other cardiovascular risk factors. Recently, it has been confirmed that several drugs in these classes, including canagliflozin, empagliflozin, semaglutide, and liraglutide, are safe and possess cardioprotective effects. We review the most recent cardiovascular outcome trials on GLP-1RAs and SGLT-2Is, and discuss their implications for treating patients with T2DM in terms of protective effects against cardiovascular disease.

Implementation of the Chronic Disease Care System and its association with health care costs and continuity of care in Korean adults with type 2 diabetes mellitus

Background

The Chronic Disease Care System (CDCS) has been implemented in Korea to encourage treatment continuity in chronic disease patients. This study investigated the effect of the introduction of the CDCS on health care costs and continuity of care in individuals with type 2 diabetes mellitus (T2DM).

Methods

The National Health Insurance data from August, 2010 to March, 2012 (pre-policy) and from May, 2012 to December, 2013 (post-policy) were used. Introduction of the CDCS was defined as the intervention. The intervention group consisted of T2DM patients participating in the program and the control group patients not participating in the program. The Difference-in-Differences (DID) method was used to estimate the differences in total health care costs for outpatient services and continuity of care between the intervention and the control group before and after the intervention period.

Results

Implementation of the CDCS was associated with decreased health care costs (β = − 46,877 Korean Won, P < 0.0001) and improved continuity of care (β = 0.0536, P < 0.0001) in the intervention group with adjustment for covariates.

Conclusion

Findings confirm an association between the adoption of the CDCS and reduced health care costs and improved continuity of care. The results reveal the potential benefits of reinforcing effective chronic disease management strategies in reducing health care costs and improving treatment continuity.

Cancer risk in 892 089 patients with psoriasis in Korea: A nationwide population-based cohort study

The relationship between psoriasis and cancer has not yet been established. The aim of this study was to evaluate the association of psoriasis with certain cancers using national statistics. All patients with psoriasis (n = 892 089; 51.7% male) and age- and sex-matched control subjects (n = 4 460 445) at a 5:1 ratio were enrolled using data from the National Health Insurance Service between 2007 and 2014 in Korea. In psoriatic subjects, overall cancer risk was higher than for subjects without psoriasis after adjusting for income level, diabetes, hypertension, dyslipidemia and place of residence (hazard ratio, 1.065; 95% CI, 1.049-1.081). The risk of cancer increased in the following order: prostate, thyroid, liver, ovarian, lung, leukemia, skin, multiple myeloma, lymphoma and testicular. The severity and sex of psoriatic patients also had different cancer risks. In psoriatic patients, a slightly increased risk for specific malignant neoplasms was shown. Therefore, periodic screening for cancer risk is recommended in patients with psoriasis.

Abdominal obesity, glucose intolerance and decreased high-density lipoprotein cholesterol as components of the metabolic syndrome are associated with the development of colorectal cancer

Metabolic syndrome (MetS) and its components has been thought to be involved in the development of colorectal cancer (CRC). However, the results is often inconsistent according to gender or anatomical location of tumor. This study aimed to investigate the association between MetS and its components and CRC development by gender and tumor location. We evaluated the data of 22,809,722 Korean individuals of the National semi-compulsive cohort who underwent regular health check-ups between 2009 and 2012. Compared to subjects without MetS components, the hazard ratio for CRC development in patients with MetS was 1.22 (95% Confidence Interval [CI] 1.20-1.24) and this association was more prominent in men than in women (HR 1.41 95% CI 1.37-1.44 vs. HR 1.23 95% CI 1.20-1.27, P for interaction < 0.001). Left-sided colon cancers were more associated with MetS among men compared to women (HR 1.70, 95% CI 1.61-1.80 vs. HR 1.43, 95% CI 1.33-1.54), while right colon cancers showed a stronger association with MetS among women than men (HR 1.63, 95% CI 1.49-1.78 vs. HR 1.34, 95% CI 1.24-1.44) (all P for interaction < 0.001, respectively). Having two MetS components was still associated with CRC development and the association was the highest when two of glucose intolerance, abdominal obesity and low high-density lipoprotein cholesterol (HDL-C) combined. Individuals with glucose intolerance, abdominal obesity or low HDL-C levels, may need to undergo thorough screening for CRC even if they do not meet the diagnostic MetS criteria.

Treatment variation related to comorbidity and complications in type 2 diabetes: A real world analysis

A complex comorbidity status may cause treatment variance interfering with type 2 diabetes (T2D) guideline-confirm therapy and influence the occurrence of complications but evidence on its relationships and alternative treatments are lacking. This study aimed to identify treatment variance and common T2D drug treatment related to comorbid status and the association with comorbidity and complications.Based on Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) databases, we conducted a retrospective, observational exploratory study including 7123 T2D patients without microvascular-, macrovascular complication. We explored patterns of comorbid status and drug treatment and its relation to the development of complications within 4-year period. Analysis was performed by two-step cluster analysis and nonlinear canonical correlation analysis.64.9% had at least one other chronic disease and 61.7% of T2D patients were treated with >1 glucose lowering drugs. 15.8% developed microvascular complications and 6.5% had ischemic heart disease or cerebrovascular complications. 82.2% of the treatment patterns were identified among T2D patients with 1 or no comorbidity while 14.4% was identified in patients with ≥2 comorbidities. Combination treatment such as, sulfonylurea or dipeptidyl peptidase-4 inhibitors combined with metformin were observed. Occurrence of microvascular- or/and macrovascular complication and its relation to comorbidity and treatment pattern was not identified.In conclusion, as number of comorbidity increased with both type of comorbidity (diabetes related-, unrelated) present, common treatment patterns were less or not identified. More treatment variance was observed in patient's groups that had developed complications.

Low serum creatinine predicts risk for type 2 diabetes

AIMS

As an insulin target tissue, skeletal muscle is inversely related to type 2 diabetes mellitus (T2DM). Serum creatinine originates mainly from creatine in muscle and is considered as a reliable surrogate marker for muscle mass in apparently healthy subjects. It is therefore hypothesized that low serum creatinine could effectively predict increased risk of T2DM. Yet information is scarce regarding the longitudinal relationship between serum creatinine and T2DM. This study aims to investigate this relation in a large general population of both men and women.

METHODS

A prospective cohort study (n = 57 587; follow-up range: 1-9 years, mean: 3.57 years, 95% confidence interval: 3.55-3.58 years) was conducted in a general population sample from Tianjin, China. Multivariable Cox proportional hazards regression models were used to assess the relationship between baseline serum creatinine and the risk of developing T2DM (as defined by the American Diabetes Association criteria).

RESULTS

During the follow-up period, 2017 subjects developed T2DM. The multivariate-adjusted hazard ratios (95% confidence interval) for T2DM incidence across quintiles of serum creatinine were 1.00 (reference), 0.86 (0.75, 0.99), 0.82 (0.72, 0.94), 0.85 (0.74, 0.97), and 0.77 (0.67, 0.89; P for trend <.01). Similar results were observed in both sexes (interaction P = .56).

CONCLUSIONS

These findings indicate that serum creatinine concentration is inversely related to incident T2DM in both men and women. Measuring serum creatinine may assist in the early detection of individuals at high risk of developing T2DM.

Cancer risk by the subtype of alopecia

The cancer risk in patients with alopecia areata (AA) or alopecia totalis (AT)/alopecia universalis (AU) remains unknown. In this study, national statistical data were used to study the association between these forms of alopecia and the risk of cancer. We enrolled 668,604 patients who were treated for alopecia from 2007 to 2014, and age- and sex-matched control subjects. AA and AT/AU patients had slightly higher overall cancer risks (hazard ratio (HR), 1.043; 95% confidence interval (CI), 1.022-1.065 and HR, 1.07; 95% CI, 1.013-1.129, respectively) than controls, after adjusting for confounding factors. The risks of oral cavity, esophagus, liver, biliary tract, pancreas, larynx, lung, kidney, breast, cervix, ovary, uterus, testis, nerve, and skin cancers; and lymphoma, multiple myeloma, and leukemia, were not increased in alopecia patients. In AA or AT/AU patients, the only increased risk was that of thyroid cancer. In AA patients alone, the risks of bladder and prostate cancers were increased. Thus, the cancer risks varied by the alopecia subtype. Careful monitoring is needed to explore if the actual risks of thyroid, bladder, and prostate cancers are increased in alopecia patients.