Utilization of Osteoporosis-Related Health Services: Use of Data from the Korean National Health Insurance Database 2008-2012

Factors Associated With Compliance and Persistence With Pharmacotherapy in Patients With Osteoporosis: A Nationwide Cohort Study in Korea

BACKGROUND

Despite the necessity of long-term management for fracture risk reduction, adherence to osteoporosis pharmacotherapy remains poor. We investigated the factors influencing adherence to pharmacotherapy among Korean patients with osteoporosis, with a particular focus on treatment with bisphosphonates (BPs).

METHODS

Data from 725,313 osteoporosis patients newly prescribed BPs or selective estrogen receptor modulators (SERMs) between 2012 and 2014, obtained from the Korean National Health Insurance Service, were analyzed. Adherence was assessed based on compliance and persistence over a two-year period, with factors associated with adherence identified using multivariable logistic regression.

RESULTS

Only 14.8% of the patients who started BPs or SERMs sustained medication compliance, with 15.8% persisting with treatment over the two-year follow-up. Compared with BPs, patients receiving SERMs showed better compliance and persistence (odds ratios [ORs], 1.44 and 1.48, respectively; P < 0.001); while patients receiving intravenous administration showed higher compliance and persistence (ORs, 2.08 and 1.76, respectively; P < 0.001) compared with those taking oral medications. Patients placed on a quarterly dosing schedule showed improved compliance and persistence (ORs, 1.55 and 1.31, respectively; P < 0.001) compared with those on other dosing intervals. Male gender, advanced age, living outside metropolitan areas, receiving treatment in non-general hospitals, and a history of previous fractures were associated with poorer two-year adherence.

CONCLUSION

This study underscores the complex nature of medication adherence among Korean osteoporosis patients, particularly those treated with BPs. These findings accordingly indicate that medication with more convenient administration regimens and fewer side effects, coupled with suitable follow-up durations, could contribute to enhancing treatment adherence.

Oral phosphate binders and incident osteoporotic fracture in patients on dialysis

BACKGROUND

End-stage kidney disease (ESKD) has an elevated risk of osteoporotic fractures in relation to mineral and bone disorder (MBD) as well as conventional risks of osteoporosis. We investigated the association between oral phosphate binders, the mainstay of MBD treatment, and osteoporotic fracture in dialysis patients.

METHODS

We obtained data from the National Health Insurance database for incident dialysis patients without a history of osteoporotic fractures. Participants were categorized into four groups based on their initial 1-year prescription profiles: calcium-based phosphate binder (CBPB), non-calcium-based phosphate binder (NCBPB), both CBPB and NCBPB (mixed), and non-phosphate binder (non-user) groups. The primary outcome was the occurrence of new-onset osteoporotic fractures after 1 year of dialysis. Secondary outcomes included cardiovascular events and mortality.

RESULTS

Out of 69 368 incident dialysis patients, 22 326, 5020, 2853 and 39 169 were included in the CBPB, NCBPB, mixed and non-user groups, respectively. The overall risk of osteoporotic fractures was lower in patients taking any phosphate binders compared with non-users. Specifically, only the CBPB group showed a reduced risk of vertebral [adjusted hazard ratio (aHR) 0.83 (0.76-0.92)], hip [aHR 0.81 (0.74-0.89)] and distal radius [aHR 0.88 (0.78-0.99)] fractures compared with non-users. This relationship presented in a time-dependent manner with fracture risk reduction in patients taking CBPB for 3-6 months [aHR 0.9 (0.83-0.99)] and ≥6 months [aHR 0.83 (0.78-0.89)], compared with those using CBPB for <3 months. Additionally, only the CBPB group had a lower risk of MACE, cardiac arrest and ventricular arrhythmia than non-users. All phosphorus binder groups showed a reduced mortality risk compared with non-users.

CONCLUSIONS

Our findings indicate that the using phosphate binders in ESKD patients is lowers the risk of osteoporotic fractures. Notably, those taking CBPB had a reduced risk without increasing cardiovascular events or mortality compared with non-users.

Effects of Anticancer Therapy on Osteoporosis in Breast Cancer Patients: A Nationwide Study Using Data from the National Health Insurance Service-National Health Information Database

Background/Objectives: This nationwide retrospective study evaluated the effects of anticancer therapy on osteoporosis in 126,132 Korean breast cancer survivors from 2002 to 2020. Methods: The Cox proportional hazards model assessed the effects of treatment on osteoporosis. To circumvent the guarantee-time bias for osteoporosis development, a landmark analysis was employed. A stabilized inverse probability of treatment weighting was performed to control any confounding bias. The propensity score was calculated using a multinomial logistic regression model with age, national health insurance, and the Charlson comorbidity index. Results: During a median follow-up of 4.22 years, 28,603 cases of osteoporosis were documented. Aromatase inhibitors (AIs) were associated with a higher risk of osteoporosis development in comparison to tamoxifen (TMX) or chemotherapy. Notably, AIs administered subsequent to a combination of chemotherapy and anti-HER2 therapy exhibited the highest risk of osteoporosis development. Subgroup analysis revealed that the mean interval from breast cancer diagnosis to osteoporosis development was 5.00 years for women diagnosed with cancer at age < 50 and 3.89 years for those diagnosed at age ≥ 60. TMX increased the risk of osteoporosis in women diagnosed with cancer at age < 50, whereas chemotherapy was not a significant risk factor for osteoporosis development in those diagnosed at age ≥ 60. The impact of anticancer therapy on osteoporosis development was more pronounced in women diagnosed with breast cancer at a younger age compared to those diagnosed at an older age. Conclusions: Effective prevention and active management strategies should be implemented to address bone loss in both younger and older breast cancer patients.

Big Data Research in the Field of Endocrine Diseases Using the Korean National Health Information Database

The Korean National Health Information Database (NHID) contains big data combining information obtained from the National Health Insurance Service and health examinations. Data are provided in the form of a cohort, and the NHID can be used to conduct longitudinal studies and research on rare diseases. Moreover, data on the cause and date of death are provided by Statistics Korea. Research and publications based on the NHID have increased explosively in the field of endocrine disorders. However, because the data were not collected for research purposes, studies using the NHID have limitations, particularly the need for the operational definition of diseases. In this review, we describe the characteristics of the Korean NHID, operational definitions of endocrine diseases used for research, and an overview of recent studies in endocrinology using the Korean NHID.

Effects of short-term exposure to air pollution on hospital admissions for autism spectrum disorder in Korean school-aged children: a nationwide time-series study

OBJECTIVES

This study explored the effects of short-term exposure to air pollution on hospital admissions for autism spectrum disorder (ASD), a proxy for symptom aggravation, among Korean children aged 5-14 years.

DESIGN

Time-series study.

SETTING, PARTICIPANTS AND OUTCOME MEASURES

We used data from the National Health Insurance Service (2011-2015). Daily concentrations of fine particulate matter (PM2.5), nitrogen dioxide (NO2) and ozone (O3) levels in each region were used as exposures. ASD cases were defined based on a principal admission diagnosis of the claims data. We applied distributed lag non-linear models and a generalised difference-in-differences method to the quasi-Poisson models to estimate the causal effects of air pollution for up to 6 days. We also performed weighted quantile sum regression analyses to assess the combined effects of air pollution mixtures.

RESULTS

PM2.5 levels at lag day 1, NO2 levels at lag day 5 and O3 levels at lag day 4 increased the risks of hospital admissions for ASD (relative risk (RR)=1.17, 95% CI 1.10 to 1.25 for PM2.5; RR=1.09, 95% CI 1.01 to 1.18 for NO2 and RR=1.03, 95% CI 1.00 to 1.06 for O3). The mean daily count of hospital admissions for ASD was 8.5, and it would be 7.3, 7.8 and 8.3 when the PM2.5 levels would be decreased by 10.0 µg/m3, NO2 by 10 ppb and O3 by 10 ppb, respectively. The weighted quantile sum index, constructed from PM2.5, NO2 and O3 levels, was associated with a higher risk of hospital admissions for ASD (RR 1.29, 95% CI 1.14 to 1.46), where NO2 was found to contribute to the effects most (the weight of 0.80).

CONCLUSIONS

These results emphasise that reduction of air pollution exposure should be considered for ASD symptom management, with important implications for the quality of life and economic costs.

Temporal change in the diagnosis and treatment rates of osteoporosis: results from the Korea National Health and Nutrition Examination Survey

To compare the diagnosis andtreatment rates of osteoporosis and diabetes in Korea, a nationwide database was used. The results showed that although osteoporosis management is improving, it is still lower compared with that of diabetes; thus, further efforts are needed in this regard.

INTRODUCTION

This study aimed to re-evaluate the diagnosis and treatment of osteoporosis from the KNHANES 2016-2017 and compare the temporal change of the rate with those of diabetes as another prevalent chronic disease in South Korea.

METHODS

The prevalence of osteoporosis in 2016 was estimated using the previous data classified by age groups (50-59,60-69, and ≥70years) and the 2016 Korean census data. The physician diagnosis and treatment rates of osteoporosis in adults aged ≥50years were estimated using the 2016-2017 KNHANES data. The physician diagnosis and treatment rates of diabetes were evaluated using the KNHANES 2008-2009 and 2016-2017 data.

RESULTS

The estimated physician diagnosisrate of osteoporosis increased from 29.9% in females and 5.8% in males in 2008-2009 to 62.8% in females and 22.8% in males in 2016-2017. The treatment rate for the estimated total number of patients with osteoporosis increased from 14.4% in females and 3.8% in males in 2008-2009 to 32.2% in females and 9.0% in males in 2016-2017. An increasing trend in the estimated treatment rateof physician-diagnosed osteoporosis patients was not observed (48.3% [2008-2009] vs 51.5% [2016-2017] in females; 42.6% [2008-2009] vs 42.2% [2016-2017] in males). The physician diagnosis and treatment rates of diabetes were considerably better and more stable than those of osteoporosis.

CONCLUSION

Osteoporosis management in South Korea is improving but is insufficient compared with diabetes management. More extensive efforts are needed to improve the diagnosis and treatment rates of osteoporosis.

Estimating the future clinical and economic benefits of improving osteoporosis diagnosis and treatment among women in South Korea: a simulation projection model from 2020 to 2040

Using a microsimulation model, the impact of increased diagnosis and treatment of postmenopausal women with osteoporosis on anticipated reduction in fractures and associated costs in South Korea from 2020 to 2040 was projected.

INTRODUCTION

The economic burden of osteoporosis was US $5.1B in 2011 in South Korea. Osteoporosis is expected to strain resources in South Korea as the population most susceptible to osteoporotic fracture, females > 50 years old, is projected to increase by 32% from 2020 to 2040.

METHODS

A microsimulation model was developed to project annual incidence and costs of osteoporotic fractures among postmenopausal women from 2020 to 2040. Fracture risk was estimated using the simplified Fracture Risk Assessment Tool (FRAX). The fracture estimates were based on annualized FRAX risk and impact of treatment. Korean National Health Insurance data informed treatment and case-finding rates in the reference case. Two scenarios were evaluated: 50% increases to (i) case finding (screening rate and subsequent treatment rate) and (ii) treatment rate among those at highest risk.

RESULTS

Among individuals modeled in the reference case from 2020 to 2040, 41.2 M fractures at a cost of US $263.6B were projected. Increased treatment scenario prevented 4.4 M fractures and saved US $13.5B. Increased case-finding scenario prevented 4.0 M fractures and saved US $11.1B.

CONCLUSION

Implementation of policies to enable increasing case finding or treatment may result in fewer fractures and substantial cost savings across the healthcare system. These results highlight the importance of early screening, diagnosis, and preventive treatment.

Osteoporosis and Osteoporotic Fracture Fact Sheet in Korea

BACKGROUND

The socioeconomic burdens of osteoporosis and related fractures have increased in parallel with population aging. The Korea Society of Bone and Mineral Research published fact sheets on these topics in 2017, 2018, and 2019. This study provides complied epidemiological data based on these fact sheets for understanding current status of osteoporosis in Korea.

METHODS

Data from the Korea National Health and Nutrition Examination Survey (2008-2011) performed by the Korea Centers for Disease Control and Prevention and from National Health Information database (2008-2016) by National Health Insurance Service of Korea was used for analyzing the prevalence and incidence of osteoporosis and related fractures, respectively, fatality rates after fractures, and prescription status of anti-osteoporotic medications (AOMs).

RESULTS

Among Korean adults aged ≥50 years, 22.4% and 47.9% had osteopenia or osteoporosis, respectively. Incidences of osteoporotic hip, vertebral, humerus, and distal radius fractures plateaued in 2013. The cumulative incidence of subsequent fractures gradually increased over 4 years of follow-up once an osteoporotic fracture occurred. Crude fatality rates in the first 12 months after hip fracture were 14.0% for women and 21.0% for men. Only 33.5% of patients with osteoporosis took AOMs, and even after an osteoporotic fracture, only 41.9% of patients took AOMs within the following 12 months. Despite a steady increase in AOM prescriptions of ~6% per annum, only 33.2% of patients were medication compliant (medication possession ratio ≥80%) at 12 months after treatment initiation.

CONCLUSIONS

Continuous efforts are required to diagnose patients at high risk of fracture and ensure proper management in Korea.

The exploration of feature extraction and machine learning for predicting bone density from simple spine X-ray images in a Korean population

OBJECTIVE

Osteoporosis is hard to detect before it manifests symptoms and complications. In this study, we evaluated machine learning models for identifying individuals with abnormal bone mineral density (BMD) through an analysis of spine X-ray features extracted by deep learning to alert high-risk osteoporosis populations.

MATERIALS AND METHODS

We retrospectively used data obtained from health check-ups including spine X-ray and dual-energy X-ray absorptiometry (DXA). Consecutively, we selected people with normal and abnormal bone mineral density. From the regions of interest of X-ray images, deep convolutional networks were used to generate image features. We designed prediction models for abnormal BMD using the image features trained by machine learning classification algorithms. The performances of each model were evaluated.

RESULTS

From 334 participants, 170 images of abnormal (T scores < - 1.0 standard deviations (SD)) and 164 of normal BMD (T scores > = - 1.0 SD) were used for analysis. We found that a combination of feature extraction by VGGnet and classification by random forest based on the maximum balanced classification rate (BCR) yielded the best performance in terms of the area under the curve (AUC) (0.74), accuracy (0.71), sensitivity (0.81), specificity (0.60), BCR (0.70), and F1-score (0.73).

CONCLUSION

In this study, we explored various machine learning algorithms for the prediction of BMD using simple spine X-ray image features extracted by three deep learning algorithms. We identified the combination for the best performance in predicting high-risk populations with abnormal BMD.

Establishment of Fracture Liaison Service in Korea: Where Is It Stand and Where Is It Going?

The elderly population growth rate is extremely high in Korean society, and life expectancy is close to 85 years old for women and 80 for men as of people born in 2015. The future hip fracture prediction model of Korea shows that the elderly hip fracture rate will increase by 1.4 times by 2025, which will impose a serious socioeconomic burden on Korean society and become a key issue of public health management. The fracture liaison service (FLS) is defined adequate treatment and services for patients over 50 years old with fragility fractures, enabling systematic identification and decreasing the risk of subsequent osteoporotic fractures. In Korean society, the introduction of FLS, which is verified not only in the socioeconomic aspects but also in the treatment of patients, is thought to be essential. However, the challenges that need to be addressed in order to implement FLS include the lack of awareness regarding the necessity of this system, the lack of healthcare systems, and inadequate policies. In the future, further studies on the FLS and its clinical and socioeconomic effects for the Korean medical system will be necessary.

The trend of osteoporosis and osteoporotic fragility fractures in inpatients: results from a national database

Osteoporosis is associated with an increased risk of pathologic fractures; however, most patients do not receive diagnosis and adequate treatment. The aim of our study was to compare the yearly trends of osteoporosis and osteoporotic fragility fractures in the USA (US) inpatients. We used National (Nationwide) Inpatient Sample database to identify adults ≥18 years with diagnoses of osteoporosis and pathologic fractures and excluded pathologic fractures due to other etiologies. We then studied the annual trends, in terms of annual percentage change (APC), of osteoporosis and osteoporotic fractures. Among overall hospitalizations, osteoporosis was noted to have an increasing trend from 2000 to 2009 (APC = 5.81, p < 0.05) with a decline thereafter (APC = - 3.88, p < 0.05). In contrast, osteoporotic fracture showed an initial downward trend from 2000 to 2010 (APC = -7.31, p < 0.05), followed by a slowly rising trend (APC = 2.0, p = NS). The initially increasing trend of osteoporosis was followed by a decreasing trend thereafter. In contrast, there was a halt in a previously declining trend of osteoporotic fracture. Potential explanations include inadequate screening and treatment per guidelines along with decreasing patient compliance. In conclusion, primary and secondary prevention measures for osteoporosis have been underutilized by both physicians and patients alike.

Biomechanical Fixation Properties of the Cortical Bone Trajectory in the Osteoporotic Lumbar Spine

OBJECTIVE

Selecting optimal strategies for improving fixation in osteoporotic lumbar spine is an important issue in clinical research. Cortical bone trajectory (CBT) screws have been proven to enhance screw pullout strength, but biomechanical efficacy of these screws remains understudied. The aim of this study was to evaluate biomechanical efficacy of CBT screws in osteoporotic lumbar spine.

METHODS

Thirty-one vertebrae from 14 cadaveric lumbar spines were obtained. All specimens were measured by computed tomography; the diameter of pedicles, excluding those of vertebral bodies with very small pedicle developments, was calculated. After measuring bone mineral density, the CBT screw was randomly inserted into 1 side, and the traditional trajectory (TT) screw was inserted into the contralateral side. Maximum insertional torque was recorded after screw insertion. Of vertebrae, 21 were subjected to pullout testing at a rate of 5 mm/minute, and 10 were subjected to cyclic fatigue testing. Each construct was loaded until exceeding 5 mm.

RESULTS

Average bone mineral density was 0.567 ± 0.101 g/cm². CBT screws had higher maximum insertional torque (degrees of freedom = 30, t = 5.78, P < 0.001, 0.333 N-m vs. 0.188 N-m) and higher axial pullout strength (degrees of freedom = 20, t = 7.41, P < 0.001, 394 N vs. 241 N) than TT screws. Increased bone mineral density was not significantly associated with higher pullout load. Compared with TT screws, CBT screws showed better resistance to fatigue testing and required more cycles to exceed 5 mm (degrees of freedom = 9, t = 5.62, P < 0.001, 6161 cycles vs. 3639 cycles). Failure load for displacing screws was also significantly greater for CBT screws than for TT screws (degrees of freedom = 9, t = 5.75, P < 0.001, 443 N vs. 317 N).

CONCLUSIONS

CBT screws had better biomechanical fixation in osteoporotic lumbar spine compared with standard pedicle screws.

Trend in Disability-Adjusted Life Years (DALYs) for Injuries in Korea: 2004-2012

BACKGROUND

Injury is a major public health problem and accounts for 10% of the global burden of disease. This study intends to present the temporal trend in the injury burden in Korea and to compare the burden size by injury mechanism and age group.

METHODS

This study was a nationwide population-based observational study. We used two data sets, the death certificates statistics and the Korean National Hospital Discharge Survey data (2004-2012). We calculated age-standardized disability-adjusted life year (DALY) from years of life lost (YLL) and years lived with disability (YLD) and trend analysis.

RESULTS

The DALYs of road injury decreased (P = 0.002), falls did not exhibit a trend (P = 0.108), and self-harm increased overall (P = 0.045). In the road injury, the YLLs decreased across all 4 age groups (0-14, 15-49, 50-79, ≥ 80) and the YLDs decreased in the 0-14-year-old group. In total, the DALYs of road injuries decreased in the 0-14-year-old group. In the fall injury, although the YLLs decreased in the over 80-year-old group, the YLDs increased in the 50-79-year-old group and the over 80-year-old group. The burden of self-harm injury was high in the age group 15 years and over, especially in the 15-49-year-old group.

CONCLUSION

The leading causes of the injury burden were road injuries, falls, and self-harm. The burden of road injury and self-harm have recently shown a gradual decreasing tendency. On the other hands, that of fall injuries are continually high in the age group over 50 years of age.