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

Reinforcing Primary Care in Korea: Policy Implications, Data Sources, and Research Methods

Korea has undergone rapid transformation, achieving significant advancements in both economic development and social security. Notably, the country achieved universal health coverage within a remarkably short period, representing a significant institutional milestone in healthcare. However, the healthcare system faces substantial challenges due to limited resources, a reliance on private healthcare providers, and a rapidly aging population which threatens its sustainability. Various efforts have been made to strengthen Korea's primary care environment. This study aims to examine the multifaceted healthcare landscape surrounding primary care in Korea, analyze associated systems to identify institutional limitations, and propose strategies to enhance primary care in the future. Additionally, it seeks to raise awareness of the current state of primary care in Korea and serves as an example for other countries striving to improve their primary care systems. Furthermore, this review provides a comprehensive overview of key data sources relevant to primary care research in Korea, such as the National Health Insurance Service claims data and the Korea Health Panel Survey. It also outlines practical research methodologies-from epidemiological studies to policy analyses-serving as a valuable reference for both domestic and international scholars seeking to enhance primary care systems.

Concurrent Medication Adherence in Hypertensive Patients With High-Risk Comorbidities

BACKGROUND

Hypertensive patients with high-risk comorbidities require medications for each condition, leading to greater burden. The number of chronic conditions can affect patients' concurrent medication adherence.

OBJECTIVE

We aimed to compare the characteristics of groups based on their concurrent medication adherence and investigate the association between the number of high-risk comorbidities and concurrent medication adherence for patients with hypertension and high-risk comorbidities.

METHODS

A secondary data analysis was performed with the 2018 Korea Health Panel Survey, including 2230 patients with hypertension and at least 1 high-risk comorbidity who were prescribed medications for at least 2 conditions. Using medication adherence for each condition, we identified 3 concurrent medication adherence groups: adherent, suboptimal, and nonadherent groups. Multinominal logistic regression was used to determine the association between the number of high-risk comorbidities and the concurrent medication adherence groups.

RESULTS

Adherent, suboptimal, and nonadherent groups included 85%, 11%, and 4% of the patients, respectively. Whereas having more high-risk comorbidities was associated with belonging to the suboptimal group compared with the adherent group (adjusted odds ratio, 1.46), having fewer high-risk comorbidities was associated with belonging to the nonadherent group compared with the adherent group (adjusted odds ratio, 0.52).

CONCLUSIONS

We identified 3 groups based on their concurrent medication adherence. Our results indicated that the relationship of the number of high-risk comorbidities with the concurrent medication adherence group was inconsistent.

Impact of Comprehensive Primary Care in Patients With Complex Chronic Diseases: Nationwide Cohort Database Analysis in Korea

BACKGROUND

More comprehensive healthcare services should be provided to patients with complex chronic diseases to better manage their complex care needs. This study examined the effectiveness of comprehensive primary care in patients with complex chronic diseases.

METHODS

We obtained 2002-2019 data from the National Health Insurance Sample Cohort Database. Participants were individuals aged ≥ 30 years with at least two of the following diseases: hypertension, diabetes mellitus, and hyperlipidemia. Doctors' offices were classified into specialized, functional, and gray-zone based on patient composition and major diagnostic categories. The Cox proportional hazard model was used to examine the association between office type and hospital admission due to all-causes, severe cardiovascular or cerebrovascular diseases (CVDs), hypertension, diabetes mellitus, or hyperlipidemia.

RESULTS

The mean patient age was 60.3 years; 55.8% were females. Among the 24,906 patients, 12.8%, 38.3%, and 49.0% visited specialized, functional, and gray-zone offices, respectively. Patients visiting functional offices had a lower risk of all-cause admission (hazard ratio [HR], 0.935; 95% confidence interval [CI], 0.895-0.976) and CVD-related admission (HR, 0.908; 95% CI, 0.844-0.977) than those visiting specialized offices. However, the admission risks for hypertension, diabetes mellitus, and hyperlipidemia were not significantly different among office types.

CONCLUSION

This study provides evidence of the effectiveness of primary care in functional doctors' offices for patients with complex chronic diseases beyond a single chronic disease and suggests the need for policies to strengthen functional offices providing comprehensive care.

Evaluating A Multicomponent Chronic Disease Management Pilot Intervention among Korean Patients with Hypertension and Diabetes

Background

A local clinic-based chronic disease management intervention including care planning, education about disease management, monitoring, and evaluation of the achievement of objects was introduced in Korea in 2019. We evaluated the effect of the intervention on medication adherence in patients with hypertension and diabetes.

Methods

In 2019, a one-year retrospective case-control group study design was performed using data from the National Health Insurance Service in Korea. Propensity score matching was used to control for selection bias. Medication adherence, calculated by medication possession rate, was the dependent variable. We conducted multivariate logistic regression analyses to examine the association between participation in the intervention and medication adherence, adjusting for covariates. A control group was set as a reference for participation in the full/partial component intervention.

Results

The proportions of participants in the full component intervention in the experimental group were 43.2% and 42.6% for patients with hypertension or diabetes, respectively. Both these groups tended to be more medication adherent than their counterparts (hypertension OR: 1.23, 95% CI 1.03-1.45, diabetes OR: 1.64, 95% CI: 1.24-2.17).

Conclusion

Institutionalizing a comprehensive chronic disease management program using multidisciplinary teams in the primary care context is crucial. Also, it is necessary to refine reimbursement payment systems.

The ecology of medical care in Korea: the association of a regular doctor and medical care utilization

BACKGROUNDS

There is no registered regular doctor system in Korea, but people voluntarily select regular doctors for medical services. This study aims to study the ecology of medical care in Korea according to the presence and type of a regular doctor.

METHODS

This study was conducted using Korean Health Panel survey in 2018. The proportion of people who had health problems and received medical care in various settings was analyzed per 1,000 people according to the following groups: without a regular doctor, having a clinic physician as a regular doctor, and having a hospital physician as a regular doctor. The adjusted odds ratio for usage of medical services was calculated.

RESULTS

Health problems and medical care use increased in the groups in this order: group without a regular doctor, group with a clinic physician as a regular doctor, the group with a hospital physician a regular doctor. Having a hospital physician as a regular doctor was associated with higher odds of inpatient care and emergency room visits, and having a clinic physician as a regular doctor was not associated with odds of inpatient care and emergency room visits when adjusting demographic and health-related variables.

CONCLUSION

Depending on whether having a regular doctor and a regular doctor's type, different ecology of medical care was observed. The position and role of a regular doctor in the context of the Korea health care system should be considered from the perspective of primary care.

Effects of morbidity on smoking cessation: a national smoking cessation program

Background

In smokers with chronic diseases, we examined the abstinence rates over 6 months and its affecting factors in the context of the Korea National Health Insurance Service (NHIS) smoking cessation program.

Methods

To identify 6-month abstinence, we extracted a sample of 15,017 participants using the multi-stage stratified cluster sampling method from the 359,047 individuals enrolled in the 2016 NHIS smoking cessation program and 1500 smokers responded to the telephone survey. From this group, 1245 individuals (48.50 ± 12.55 years; men 89.8%) were enrolled, as they had no missing information for confounding variables. We compared chronic disease distribution between participants and current smokers in the 2016 Korea National Health and Nutrition Examination Survey. We evaluated the factors affecting continuous abstinence rate (CAR) across patients with different chronic diseases: hypertension, diabetes mellitus (DM), dyslipidemia (DL), chronic obstructive pulmonary disease, and major depressive disorder (MDD).

Results

While participation of DM patients was high, the participation of DL patients was relatively low. The CAR over 6 months was 44.74%. The adjusted odds ratio (OR) for continuous abstinence over 6 months was significantly lower in the MDD group than in the no-MDD group (OR 0.43, 95% confidence interval [CI] 0.21 to 0.85). The factors of program completion (complete versus incomplete: OR 3.11, 95% CI 2.43 to 3.98), region (non-metropolitan areas versus Seoul metropolitan area: OR 1.28, 95% CI 1.01 to 1.61), and nicotine dependence (severe versus light or moderate: OR 0.64, 95% CI 0.50 to 0.83) were significantly associated with CAR.

Conclusions

The smoking cessation program was not actively recruiting smokers with chronic diseases. The CARs in each disease group were not different from those in the non-disease groups, except that the MDD group had a lower CAR over 6 months than the no-MDD group. Recruiting smokers with chronic diseases and improving their CARs depends on the careful identification of their characteristics.

Patterns of Multimorbidity in Adults: An Association Rules Analysis Using the Korea Health Panel

This study aimed to identify the prevalence and patterns of multimorbidity among Korean adults. A descriptive study design was used. Of 11,232 adults aged 18 and older extracted from the 2014 Korean Health Panel Survey, 7118 had one or more chronic conditions. The chronic conditions code uses the Korean Standard Classification of Diseases. Association rule analysis and network analysis were conducted to identify patterns of multimorbidity among 4922 participants with multimorbidity. The prevalence of multimorbidity in the overall population was 34.8%, with a higher prevalence among women (40.8%) than men (28.6%). Hypertension had the highest prevalence in both men and women. In men, diabetes mellitus and hypertension yielded the highest probability of comorbidity (10.04%). In women, polyarthrosis and hypertension yielded the highest probability of comorbidity (12.51%). The results of the network analysis in four groups divided according to gender and age showed different characteristics for each group. Public health practitioners should adopt an integrated approach to manage multimorbidity rather than an individual disease-specific approach, along with different strategies according to age and gender groups.

Regional Variation of Hospitalization Rates for Asthma in Korea: Association with Ambient Carbon Monoxide and Health Care Supply

This study was performed to investigate the relationship between the hospitalization rate for asthma and the ambient carbon monoxide (CO) by examining regional variation of the hospitalization rates for asthma in Korea and its factors. The hospital inpatient claims for asthma were acquired from the National Health Insurance database in 2015. A multivariate linear regression was performed with the hospitalization rate for asthma as a dependent variable. The annual ambient concentration of CO showed a negative association with the hospitalization rates for asthma while that of sulfur dioxide showed a positive association. The number of primary care physicians showed a negative association with the hospitalization rates for asthma while the number of beds in hospitals with less than 300 beds showed a positive association. The negative association of the ambient concentration of CO with the hospitalization rates for asthma showed results upon further investigation.

Geographic variation and factors associated with rates of knee arthroplasty in Korea-a population based ecological study

Background

The recent increase in knee arthroplasty (KA) use in Korea is among the highest in the world. The rapid increase in KA use suggests that the KA use in Korea could have been affected by medically unjustifiable factors. This study aimed to examine the geographic variation in the rate of KA and its associated factors in Korea.

Methods

We used the data from the National Health Insurance in Korea in 2013, from which a total of 67,086 claims for KA were obtained. We calculated the age-sex-standardized KA rates of the entire population and the crude rates of the age groups 0–64 and 65 and over in 251 districts. We assessed the geographic variation of the KA rates and examined the associated factors with a multivariate linear regression with the KA rate as a dependent variable.

Results

The overall rate of KA in Korea was 132.7 per 100,000 persons. The rates of KA showed a four-fold variation. The deprivation index score and the number of beds in the small to medium sized hospitals showed a positive association with the rates of KA while the number of orthopedic surgeons showed a negative association.

Conclusions

Korea has been experiencing a rapid increase in the use of KA for the last decade or so, which was most prominent among the elderly population aged 65 and older. Our results suggest that the higher rate of KA is strongly related to a higher supply of beds and the socioeconomically deprived conditions. Considering that the decision concerning KA has room for discretion and also affects a considerable portion of health care expenditures, the use of KA should be thoroughly monitored with more emphasis on standardization in the decision making process and preventive measures that can lessen the need for KA.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2766-y) contains supplementary material, which is available to authorized users.

Hospitalizations for ambulatory care sensitive conditions as an indicator of access to primary care and excess of bed supply

BACKGROUND

Ambulatory care sensitive conditions (ACSC) hospitalization is a widely accepted measure of the access to primary care. However, given its discretionary characteristics, the ACSC hospitalization can be a measure reflecting the influence of hospital bed supply. In Korea, where the quality of primary care and oversupply of hospital beds are coexistent concerns, ACSC hospitalization can be used to examine the impact of both factors. This study was performed to investigate the ACSC hospitalization rate as a measure of the hospital bed supply as well as access to primary care.

METHODS

Data were obtained from the National Health Insurance Database for 2015. We calculated the age-sex standardized hospitalization rates for ACSC in the total population and crude rates of ACSC hospitalization for three different age groups in 252 districts in Korea. We calculated the variation statistics of ACSC hospitalization rates, and we estimated a linear regression model to investigate the factors for ACSC hospitalization.

RESULTS

There was a very high geographic variation in ACSC hospitalization rates. Higher density of primary care physicians was associated with a decreased ACSC hospitalization rate while a higher density of hospital beds in small to medium sized hospitals was associated with an increased rate. The deprivation index score had a strongly positive association with the ACSC hospitalization rates.

CONCLUSION

ACSC hospitalization, while being a negative index of primary care access, can also be a measure indicating the impact of the hospital bed supply, and it is still a valid measure of the disparity of health care, the original motivation for this topic.

A spatial analysis of geographic variation and factors associated with hospitalization for bacterial pneumonia in Korea

BACKGROUND

The incidence of pneumonia in Korea started to increase in the 1990's after a period of decrease and stabilization, and the mortality and hospitalization rates for pneumonia in Korea are alarmingly high. This study was performed to examine geographic variation and factors associated with hospitalization for bacterial pneumonia in Korea.

METHODS

Data were acquired from the inpatient claims of the 2015 period of the National Health Insurance Service. The age- and sex-standardized hospitalization rates for bacterial pneumonia were calculated for three age groups. Geographic variation was measured with the coefficient of variation, the ratio of the 90th to the 10th percentile of the distribution of rates, and the systematic component of variation. Considering the results of Moran's I statistic which suggested spatial autocorrelation, we estimated spatial regression models using spatial error models.

RESULTS

The hospitalization rate for bacterial pneumonia was 79.1 per 10,000 population, and the rate was the highest in the age group 0-14 at 325.3, and it was 161.5 among the elderly. The geographic variation statistics showed high variation with the coefficient variation at 0.6. The deprivation score showed positive associations, and the number of primary care physicians had a negative association with the hospitalization rates across all age groups but the age group 0-14. The number of beds in hospitals with less than 300 beds had a positive association with the hospitalization rates for bacterial pneumonia, and the impact was the strongest in the age group 0-14.

CONCLUSIONS

The present study shows that pneumonia can be a major public health issue even in a developed country. Socioeconomic conditions can still be a concern for pneumonia in developed countries, and the role of primary care physicians in preventing hospitalization for bacterial pneumonia needs to be recognized. Most of all, the strong impact of hospital beds on the hospitalization rates for pneumonia, especially for the children, should be addressed. High disease burden of pneumonia in Korea can partly be attributable to oversupply of hospital beds. These factors should be taken into consideration in establishing policy measures for the rise in pneumonia.

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

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

Primary Care Comprehensiveness Can Reduce Emergency Department Visits and Hospitalization in People with Hypertension in South Korea

Hypertension has been the leading risk factor contributing to cardiovascular morbidity and mortality, which needs comprehensive measures to manage and can be controlled effectively in primary care. In the health care context of South Korea, where specialists can see patients directly at their own community clinics and there has been no consensus on the definition of primary care, the authors used the nationally representative 2013 Korea Health Panel data, categorized adults (≥18 years) with hypertension by types of usual source of care (USC), and analyzed the association of having a comprehensive community clinic (i.e., primary care) physician as a USC with experience of emergency department (ED) visits and hospitalization within a year. After adjusting for cofounding variables including Charlson comorbidity index scores, those having a primary care physician as a USC remained associated with a decrease in an experience of ED visits (OR: 0.61, 95% CI: 0.40–0.93) and hospitalization (OR: 0.69, 95% CI: 0.49–0.96), compared to those not having a usual physician. Health policies that promote having a primary care physician as a USC could decrease unnecessary experience of ED visits and hospitalization by adults with hypertension. This can partly reduce ED overcrowding and avoidable hospitalization in Korea.

Pediatric fluoroquinolone prescription in South Korea before and after a regulatory intervention: A nationwide study, 2007-2015

Objective

To investigate the impact of national implementation of age restriction on fluoroquinolone prescription in children and adolescents.

Methods

Data collected from the database of Health Insurance Review and Assessment Service in South Korea, a national health insurance system to analyze fluoroquinolone prescribing practice in children and adolescents younger than 18 years, between 2007 and 2015. The age restriction was implemented in December 2009. The annual prescription rate of FQ per 100,000 person-years was calculated and an autoregressive model was used to predict the prescription pattern if an intervention had not occurred.

Results

A total of 505,859 children received systemic fluoroquinolone during the study period—297,054 ciprofloxacin, and 208,805 levofloxacin. After implementation of the drug utilization review program, the annual prescription rate for ciprofloxacin declined by 97.5% (from 840 to 21 per 100,000 person-years, P < 0.001), and for levofloxacin by 96.4% (from 598 to 11 per 100,000 person-years, P < 0.001). The decline was more dramatic in the outpatient setting than in the inpatient setting for both drugs.

Conclusion

The dramatic and sustained decline in prescription number and change in prescription pattern after the regulatory action suggests that the implementation under drug utilization review program was successful in controlling excessive and inappropriate use of fluoroquinolones in children, possibly guiding towards more judicious and selective prescription behavior.