Polypharmacy and associated factors in South Korean elderly patients with dementia: An analysis using National Health Insurance claims data

BACKGROUND

Dementia is accompanied by several symptoms, including cognitive function decline, as well as behavioral and psychological symptoms. Elderly patients with dementia often experience polypharmacy, the concurrent use of multiple medications, due to chronic comorbidities. However, research on polypharmacy in patients with dementia is limited. This study aimed to characterize polypharmacy and associated factors among elderly patients with dementia in South Korea, and compare the characteristics of patients with and without dementia patients.

METHODS

From the National Health Insurance Service (NHIS)-Senior cohort database, we extracted data on patients aged≥60 years who received outpatient treatment in 2019. Polypharmacy was defined as the concurrent use of five or more different oral medications for ≥90 days; excessive polypharmacy referred to the concurrent use of ten or more different oral medications for ≥90 days. We compared the prevalence of polypharmacy between patients with and without and identified the associated factors using a logistic regression model.

RESULTS

About 70.3% and 23.7% of patients with dementia exhibited polypharmacy and excessive polypharmacy, respectively. After adjusting for conditions such as age and Charlson's comorbidity index, the likelihood of polypharmacy and excessive polypharmacy significantly increased over time after the diagnosis of dementia. Additionally, under the same conditions, Medical Aid beneficiaries with dementia were more likely to experience polypharmacy and excessive polypharmacy compared to patients with dementia covered by National Health Insurance (NHI).

CONCLUSION

This study reports the latest evidence on the status and risk factors of polypharmacy in elderly patients with dementia. We proposed that careful monitoring and management are required for patients at high risk for polypharmacy.

[Differences in Billing Patterns Between GPs and Pediatricians Using Early Diagnostics in Children and Adolescents as an Example: Analysis of Nationwide Data from Statutory Health Insurance Physicians]

BACKGROUND

Despite a 13.1% increase in the number of pediatricians between 2011 - 2020, the capacity of pediatric care has largely stagnated. This is due to increasing flexibility in working hours and a declining willingness of doctors to establish practices. In addition, there is an imbalance in the distribution of pediatric medical care capacities. While metropolitan areas are often characterized by oversupply, there is an increasing shortage of pediatricians, especially in rural areas. As a result, general practitioners in rural areas are increasingly taking over part of pediatric care. We quantify this compensation effect using the example of examinations of general health and normal child development (U1-U9).

METHODS

Basis of the analysis was the Doctors' Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) from 2015 (4th quarter). Nationwide data from the National Association of Statutory Health Insurance Physicians (KBV) for general practitioners and pediatricians from 2015 was evaluated. In the first step, the EBM was used to determine the potential overlap of services between the two groups of doctors. The actual compensation between the groups was quantified using general health and normal child development as an example.

RESULTS

In section 1.7.1 (early detection of diseases in children) of the EBM, there is a list of 16 options for services that can be billed (fee schedule positions, GOP) by general practitioners and pediatricians. This particularly includes child examinations U1 to U9. The analysis of the national data of the KBV for the early detection of diseases in children showed significant differences between rural and urban regions in the billing procedure. Nationwide, general practitioners billed 6.6% of the services in the area of early detection of diseases in children in 2015. In rural regions this share was 23% compared to 3.6% in urban regions. The analysis of the nationwide data showed that the proportion of services billed by general practitioners was higher in rural regions than in urban regions.

CONCLUSION

The EBM allows billing of services by both general practitioners and pediatricians, especially in the area of general GOP across all medical groups. The national billing data of the KBV shows that general practitioners in rural regions bill more services from the corresponding sections than in urban regions.

Delivery of index-linked HIV testing for children: learnings from a qualitative process evaluation of the B-GAP study in Zimbabwe

BACKGROUND

Index-linked HIV testing for children, whereby HIV testing is offered to children of individuals living with HIV, has the potential to identify children living with undiagnosed HIV. The "Bridging the Gap in HIV Testing and Care for Children in Zimbabwe" (B-GAP) study implemented and evaluated the provision of index-linked HIV testing for children aged 2-18 years in Zimbabwe. We conducted a process evaluation to understand the considerations for programmatic delivery and scale-up of this strategy.

METHODS

We used implementation documentation to explore experiences of the field teams and project manager who delivered the index-linked testing program, and to describe barriers and facilitators to index-linked testing from their perspectives. Qualitative data were drawn from weekly logs maintained by the field teams, monthly project meeting minutes, the project coordinator's incident reports and WhatsApp group chats between the study team and the coordinator. Data from each of the sources was analysed thematically and synthesised to inform the scale-up of this intervention.

RESULTS

Five main themes were identified related to the implementation of the intervention: (1) there was reduced clinic attendance of potentially eligible indexes due to community-based differentiated HIV care delivery and collection of HIV treatment by proxy individuals; (2) some indexes reported that they did not live in the same household as their children, reflecting the high levels of community mobility; (3) there were also thought to be some instances of 'soft refusal'; (4) further, delivery of HIV testing was limited by difficulties faced by indexes in attending health facilities with their children for clinic-based testing, stigma around community-based testing, and the lack of familiarity of indexes with caregiver provided oral HIV testing; (5) and finally, test kit stockouts and inadequate staffing also constrained delivery of index-linked HIV testing.

CONCLUSIONS

There was attrition along the index-linked HIV testing cascade of children. While challenges remain at all levels of implementation, programmatic adaptations of index-linked HIV testing approaches to suit patterns of clinic attendance and household structures may strengthen implementation of this strategy. Our findings highlight the need to tailor index-linked HIV testing to subpopulations and contexts to maximise its effectiveness.

Long-Term Rehabilitation Utilization Pattern Among Stroke Patients Under the National Health Insurance Program

OBJECTIVE

The aim of this study was to understand the frequency of patients receiving rehabilitation services at various periods after stroke and the possible medical barriers to receiving rehabilitation.

DESIGN

A retrospective cohort study was conducted using a nationally representative sample in Taiwan. A total of 14,600 stroke patients between 2005 and 2011 were included. Utilization of physical therapy or occupational therapy at different periods after stroke onset was the outcome variable. Individual and geographic characteristics were investigated to determine their effect on patients' probability of receiving rehabilitation.

RESULTS

More severe stroke or more comorbid diseases increased the odds of receiving physical therapy and occupational therapy; older age was associated with decreased odds. Notably, sex and stroke type influenced the odds of rehabilitation only in the early period. Copayment exemption lowered the odds of rehabilitation in the first 6 mos but increased the odds in later periods. Rural and suburban patients had significantly lower odds of receiving physical therapy and occupational therapy, as did patients living in areas with fewer rehabilitation therapists.

CONCLUSIONS

Besides personal factors, geographic factors such as urban-rural gaps and number of therapists were significantly associated with the utilization of post-stroke rehabilitation care. Furthermore, the influence of certain factors, such as sex, stroke type, and copayment exemption type, changed over time.

Pulmonary Metastasectomy in Colorectal Cancer: A Population-Based Retrospective Cohort Study Using the Korean National Health Insurance Database

PURPOSE

The study aimed to investigate the current status and prognostic factors for overall survival in patients who had undergone pulmonary metastasectomy for colorectal cancer.

MATERIALS AND METHODS

The data of 2,573 patients who had undergone pulmonary metastasectomy after surgery for colorectal cancer between January 2009 and December 2014 were extracted from the Korean National Health Insurance Service claims database. Patient-, colorectal cancer-, pulmonary metastasis-, and hospital-related factors were analyzed using the Kaplan-Meier method, log-rank test, and Cox proportional hazards analysis to identify prognostic factors for overall survival after pulmonary metastasectomy.

RESULTS

The mean age of the patients was 60.9±10.5 years; 66.2% and 79.1% of the participants were male and had distally located colorectal cancer, respectively. Wedge resection (71.7%) was the most frequent extent of pulmonary resection; 21.8% of the patients underwent repeated pulmonary metastasectomies; 73% of pulmonary metastasectomy cases were performed in tertiary hospitals; 53.9% of patients were treated in Seoul area; 82% of patients received chemotherapy in conjunction with pulmonary metastasectomy. The median survival duration was 51.8 months. The 3- and 5-year overall survival rates were 67.7% and 39.4%, respectively. In multivariate analysis, female sex, distally located colorectal cancer, pulmonary metastasectomy-only treatment, and high hospital volume (> 10 pulmonary metastasectomy cases/yr) were positive prognostic factors for survival.

CONCLUSION

Pulmonary metastasectomy seemed to provide long-term survival of patients with colorectal cancer. The female sex, presence of distally located colorectal cancer, and performance of pulmonary metastasectomy in high-volume centers were positive prognostic factors for survival.

Estimating the Theoretical Cost Implications of Funding New Drugs Considered Not to Be Cost-Effective

This study aims to estimate the theoretical excess expenditure that would be incurred by the Irish state-payer, should drugs be reimbursed at their original asking ("list") price rather than at a price at which the drug is considered cost-effective. In Ireland, all new drugs are evaluated by the National Centre for Pharmacoeconomics. For this study, drugs that were submitted by pharmaceutical companies from 2012 to 2017 and considered not cost-effective at list price were reviewed. A total of 43 such drugs met our inclusion criteria, and their pharmacoeconomic evaluations were further assessed. The price at which the drug could be considered cost-effective (cost-effective price) at the upper cost-effectiveness threshold used in Ireland (€ 45 000/quality adjusted life-year) was estimated for 18 drugs with an available cost-effectiveness model. Then, for each drug, the list price and cost-effective price (both per unit) were both individually applied to 1 year of national real-world drug utilization data. This allowed the estimation of the expected expenditures under the assumptions of list price paid and cost-effective price paid. The resulting theoretical excess expenditure, the expenditure at list price minus the expenditure at the cost-effective price, was estimated to be €108.2 million. This estimate is theoretical because of the confidentiality of actual drug prices. The estimation is calculated using the list price and likely overestimates the actual excess expenditure, which would reduce to zero if cost-effective prices are agreed. Nevertheless, this estimate illustrates the importance of a process to assess the value of new drugs so that potential excess drug expenditure is identified.

The prevalence, incidence, and admission rate of diagnosed schizophrenia spectrum disorders in Korea, 2008-2017: A nationwide population-based study using claims big data analysis

This study estimated the prevalence and incidence rate of schizophrenia, schizotypal, and delusional disorders (SSDD) in Korea from 2008 to 2017 and analyzed the hospital admission rate, re-admission rate, and hospitalization period. It used the Korean nationwide National Health Insurance Service claims database. SSDD patients who had at least one visit to Korea's primary, secondary, or tertiary referral hospitals with a diagnosis of SSDD, according to the International Classification of Diseases, 10th Revision (ICD-10), were identified as SSDD cases if coded as F20-F29. Data were analyzed using frequency statistics. Results showed that the 12-month prevalence rate of SSDD increased steadily from 0.40% in 2008 to 0.45% in 2017. Analysis of the three-year cumulative prevalence rate of SSDD showed an increase from 0.51% in 2011 to 0.54% in 2017. In 2017, the five-year cumulative prevalence rate was 0.61%, and the 10-year cumulative prevalence rate was 0.75%. The hospital admission rate among SSDD patients decreased from 2008 (30.04%) to 2017 (28.53%). The incidence of SSDD was 0.05% and no yearly change was observed. The proportion of SSDD inpatients whose first hospital visit resulted in immediate hospitalization was 22.4% in 2017. Epidemiological indicators such as prevalence, incidence, and hospitalization rate play an important role in planning social and financial resource allocation. Therefore, efforts to produce more accurate epidemiological indicators are very important and this study's findings could have a significant social impact.

The Risks of Corneal Surface Damage in Aqueous-Deficient Dry Eye Disease: A 17-Year Population-Based Study in Taiwan

PURPOSE

To investigate the epidemiologic characteristics and risk of corneal surface damage in patients with aqueous-deficient dry eye disease (DED) in Taiwan.

DESIGN

Retrospective, population-based cohort study.

METHODS

We used claims data in the Taiwan National Health Insurance Research Database from 1997 to 2013 of patients with DED, defined according to diagnoses, drug codes, and clinical follow-up. A comparison cohort without DED was selected through propensity score matching. The main outcome measures were corneal surface damage, including corneal erosion, corneal ulcers, or corneal scars.

RESULTS

Patients with DED had a significantly higher rate of corneal surface damage (hazard ratio [HR]: 2.70; 95% confidence interval [CI] 2.38-3.06, P < .001), especially higher in patients aged <18 years (HR 6.66; 95% CI 3.58-12.41) than in older patients and in women (HR 2.98; 95% CI 2.57-3.46) than in men (HR 2.22; 95% CI 1.78-2.77), compared to those in the non-DED cohort. DED with diabetes mellitus (P = .002), rheumatoid arthritis (P = .029), or systemic lupus erythematosus (P = .005) was positively associated with corneal surface damage. The overall prevalence of DED was 7.85%, higher among women (10.49%) than men (4.92%), and increased with age (0.53%, 3.94%, 10.08%, and 20.72% for ages <18, 18-39, 40-64, and >65 years, respectively). The prevalence increased gradually during the study period.

CONCLUSIONS

The younger age group (<18 years) had the highest risk of corneal surface damage in aqueous-deficient DED. Other predisposing factors included female sex, diabetes, and autoimmune diseases. To improve clinical care, special attention is required for patients with DED with these risk factors.

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

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

Synergy between the pay-for-performance scheme and better physician-patient relationship might reduce the risk of retinopathy in patients with type 2 diabetes

AIMS/INTRODUCTION

This study investigated whether participation by patients with type 2 diabetes in Taiwan's pay-for-performance (P4P) program and maintaining good continuity of care (COC) with their healthcare provider reduced the likelihood of future complications, such as retinopathy.

MATERIALS AND METHODS

The analysis used longitudinal panel data for newly diagnosed type 2 diabetes from the National Health Insurance claims database in Taiwan. COC was measured annually from 2003 to 2013, and was used to allocate the patients to low, medium and high groups. Cox regression analysis was used with time-dependent (time-varying) covariates in a reduced model (with only P4P or COC), and the full model was adjusted with other covariates.

RESULTS

Despite the same significant effects of treatment at primary care, the Diabetes Complications Severity Index scores were significantly associated with the development of retinopathy. After adjusting for these, the hazard ratios for developing retinopathy among P4P participants in the low, medium and high COC groups were 0.594 (95% confidence interval [CI] 0.398-0.898, P = 0.012), 0.676 (95% CI 0.520-0.867, P = 0.0026) and 0.802 (95% CI 0.603-1.030, P = 0.1062), respectively. Thus, patients with low or median COC who participated in the P4P program had a significantly lower risk of retinopathy than those who did not.

CONCLUSIONS

Diabetes care requires a long-term relationship between patients and their care providers. Besides encouraging patients to participate in P4P programs, health authorities should provide more incentives for providers or patients to regularly survey patients' lipid profiles and glucose levels, and reward the better interpersonal relationship to prevent retinopathy.

Evidence of the effect of primary care expansion on hospitalizations: Panel analysis of 143 municipalities in the Brazilian Amazon

BACKGROUND

The Family Health Strategy (FHS) became consolidated as a primary care model and gatekeeper for the Unified Health System (Sistema Único de Saúde, SUS) in the Brazil and it is considered one of the largest primary health care programmes in the world. Its rapid expansion allowed the SUS to meet the changing health care needs of the population remote localities of Brazilian municipalities.

METHODS

In the present study, exploratory data analysis was performed using modelling to provide a general overview of the study and to delineate possible structural characteristics of the cross-sectional time-series data. Panel regression methods were used to assess the association between FHS coverage and ambulatory care-sensitive hospitalizations (ACSH rates) in the municipalities of Pará, in the Brazilian Amazon, from 2008 to 2017.

RESULTS

The results showed strong evidence for the association between FHS coverage and ACSH rates, including reductions of 22% in preventable hospitalizations and 15% in hospital expenses that were directly linked to the 40% increase in FHS population coverage during the evaluated period. This expansion of primary care has mainly benefitted areas that are difficult to access and populations that were previously deprived of health care in the vast Amazon territory.

CONCLUSIONS

The findings of this study show that the increase of the expansion of primary care reduces the preventable hospitalization and the hospital expenses. This reinforces the need for public protection of the health of populations at risk and the positive impacts of primary care in the Brazilian Amazon.

Trends in the incidence and prevalence of end-stage renal disease with hemodialysis in entire Korean population: A nationwide population-based study

Data on the overall epidemiology and temporal trends of end-stage renal disease (ESRD) requiring hemodialysis in Korea are scarce. We aimed to estimate the prevalence and incidence of ESRD requiring hemodialysis in Korea between 2002 and 2017.Using the National Health Insurance Service database, we analyzed data from the entire Korean population between 2002 and 2017. Hemodialysis patients were identified using rare incurable disease codes (V001) or prescription of medical fee codes of hemodialysis (O7020 and O7021). We only included patients who had been maintained on hemodialysis for more than 90 days from the date of dialysis initiation, to exclude patients who required short-term dialysis for acute kidney injury, conversion to peritoneal dialysis, or kidney transplantation.During the 16-year follow-up, the number of hemodialysis patients in Korea has steadily increased from 11,215 in 2002 to 67,486 in 2017. The mean age of these patients has gradually increased from 55.57 ± 13.31 years in 2002 to 62.13 ± 13.23 years in 2017. In 2017, the crude prevalence rate of hemodialysis was 1303.4 per million population. Overall, the number of men tended to be somewhat higher than that of women, and the proportion of men increased slightly from 55.56% in 2002 to 58.45% in 2017. The proportion of diabetic patients increased rapidly from 23.84% to 47.84%, and the percentage of dyslipidemic patients rose from 18.9% to 86.7%. The number of incident hemodialysis patients increased significantly from 4406 in 2003 to 12,134 in 2014, and then decreased to 8090 in 2017. In the incident cases of hemodialysis, the observed increase in the proportion of male patients and in diabetes and dyslipidemia were similar to that of prevalent patients. The more recent era of hemodialysis initiation, the better 5-year survival rates were observed.The prevalence and incidence of hemodialysis in Korea gradually increased between 2002 and 2017. The proportion of men, and patients with diabetes and dyslipidemia requiring hemodialysis also increased continuously. The survival rate of hemodialysis patients was gradually improving. These findings may serve as a reference for future epidemiological studies on hemodialysis in Korea.

Impact of Covid-19 pandemic on obstetric fistula repair program in Zimbabwe

The advent of Covid-19 pandemic adversely affected many programs worldwide, public health, including programming for obstetric fistula were not spared. Obstetric fistula is an abnormal connection between the vagina and the bladder or the rectum resulting from obstetric causes, mainly prolonged obstructed labour. Zimbabwe has two obstetric fistula repair centers. Because the program uses specialist surgeons from outside the country, the repairs are organized in quarterly camps with a target to repair 90 women per quarter. This study aimed at assessing the impact of restrictions on movement and gathering of people brought about by the Cocid-19 pandemic and to characterize participants of the camp which was held in the midst of the Covid-19 pandemic at Mashoko Hospital. Specifically it looked at how Covid-19 pandemic affected programming for obstetric fistula repair and characterized participants of the fistula camp held in November to December 2020 at one of the repair centers. A review of the dataset and surgical log sheets for the camp and national obstetric fistula dataset was conducted. Variables of interest were extracted onto an excel spreadsheet and analyzed for frequencies and proportions. Data were presented in charts, tables and narratives. The study noted that Covid-19 pandemic negatively affected performance of fistula repairs greatly with only 25 women repaired in 2020 as compared to 313 in 2019. Ninety women were called to come for repairs but 52 did not manage to attend due to reasons related to the restriction of the Covid-19 pandemic lockdown. Two thirds of those women suffered from urinary incontinence while the other third had fecal incontinence. The successful repair rate was 92%. This study concluded that the pandemic greatly affected programming of fistula repair in the country and recommended the Ministry of Health and Child Care to institute measures to resume programming as soon as the situation allows.

Rolling out the radical cure for vivax malaria in Asia: a qualitative study among policy makers and stakeholders

BACKGROUND

Wide-spread implementation of treatment regimens for the radical cure of vivax malaria is hindered by a range of factors. This has resulted in an increase in the relative proportion of vivax malaria and is an important obstacle in the achievement of global malaria elimination by 2030. The main objective of this study was to explore the current policies guiding the treatment plans on vivax malaria, and the factors affecting the implementation of radical cure in South/South East Asian and Asian Pacific countries.

METHODS

This was a qualitative study among respondents who represented national malaria control programmes (NMCPs) or had a role and influence in the national malaria policies. 33 respondents from 17 countries in South/South East Asia and Asia Pacific participated in interviews between October 15 and December 15, 2020. Semi-structured interviews were conducted virtually except for two face to face interviews and audio-recorded. Transcribed audio-records underwent thematic analysis using QSR NVivo.

RESULTS

Policies against vivax malaria were underprioritized, compared with the focus on falciparum malaria and, in particular, drug resistant Plasmodium falciparum strains. Despite the familiarity with primaquine (PQ) as the essential treatment to achieve the radical cure, the respondents contested the need for G6PD testing. Optional G6PD testing was reported to have poor adherence. The fear of adverse events led health workers to hesitate prescribing PQ. In countries where G6PD was mandatory, respondents experienced frequent stockouts of G6PD rapid diagnostic kits in peripheral health facilities, which was compounded by a short shelf life of these tests. These challenges were echoed across participating countries to various degrees. Most respondents agreed that a shorter treatment regimen, such as single dose tafenoquine could resolve these problems but mandatory G6PD testing will be needed. The recommendation of shorter regimens including tafenoquine or high dose PQ requires operational evidence demonstrating the robust performance of point of care G6PD tests (biosensors).

CONCLUSION

There was sparse implementation and low adherence to the radical cure in South/South East Asian and Asian pacific countries. Shorter treatment regimens with appropriate point of care quantitative G6PD tests may resolve the current challenges. Operational evidence on point of care quantitative G6PD tests that includes the feasibility of integrating such tests into the radical cure regimen are critical to ensure its implementation.

Metformin use in cancer survivors with diabetes reduces all-cause mortality, based on the Korean National Health Insurance Service between 2002 and 2015

Malignant neoplasms are the leading cause of death in Korea. We aimed to examine if metformin use in cancer survivors reduces all-cause mortality. This study was retrospectively designed based on data from the Korean National Health Insurance Service-National Health Screening Cohort (HEALS) between 2002 and 2015. The Kaplan-Meier estimator and log-rank test was performed to estimate the survival function according to metformin usage (3721 metformin non-users with diabetes, 5580 metformin users with diabetes, and 24,483 non-diabetic individuals). Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality were calculated using Cox proportional hazards regression models.The median follow-up duration was 4.2 years. The HRs (95% CIs) for all-cause mortality of metformin users and the non-diabetic group were 0.762 (0.683-0.850) and 1.055 (0.966-1.152) in men and 0.805 (0.649-0.999), and 1.049 (0.873-1.260) in women, respectively, compared with metformin non-users among diabetic cancer survivors, in a fully adjusted model. After stratifying metformin users into pre- and post-diagnosis of cancers, adjusted HRs (95% CIs) of pre- and post-diagnosis metformin users for all-cause mortality were 0.948 (0.839-1.071) and 0.530 (0.452-0.621) in men and 1.163 (0.921-1.469) and 0.439 (0.323-0.596) in women, respectively.Metformin use in cancer survivors with diabetes reduced overall mortality rates. In particular, metformin use after cancer diagnosis, not before cancer diagnosis, was inversely associated with overall mortality.Active treatment with metformin for diabetic cancer survivors after cancer diagnosis can improve their survival rates.

Is the National Health Insurance Scheme helping pregnant women in accessing health services? Analysis of the 2014 Ghana demographic and Health survey

BACKGROUND

Increasing the use of healthcare is a significant step in improving health outcomes in both the short and long term. However, the degree of the relationship between utilization of health services and health outcomes is affected by the quality of the services rendered, the timeliness of treatment and follow-up care. In this study, we investigated whether the National Health Insurance Scheme (NHIS) is helping pregnant women in accessing health services in Ghana.

METHODS

Data for the study were obtained from the women's file of the 2014 Ghana Demographic and Health Survey. All women with birth history and aged 15-49  constituted our sample (n = 4271). We employed binary logistic regression analysis in investigating whether the NHIS was helping pregnant women in accessing health service. Statistical significance was set at <0.05.

RESULTS

Most women had subscribed to the NHIS [67.0%]. Of the subscribed women, 78.2% indicated that the NHIS is helping pregnant women in accessing healthcare. Women who had subscribed to the NHIS were more likely to report that it is helping pregnant women in accessing health service [aOR = 1.70, CI = 1.38-2.10]. We further noted that women who had at least four antenatal visits were more likely to indicate that NHIS is helping pregnant women in accessing health services [aOR = 3.01, CI = 2.20-4.14]. Women with secondary level of education [aOR= 1.42; CI: 1.04-1.92] and those in the richest wealth quintile [aOR = 3.51; CI = 1.94-6.34] had higher odds of indicating that NHIS is helping pregnant women in accessing healthcare. However, women aged 45-49 [aOR = 0.49; CI = 0.26-0.94], women in the Greater Accra [aOR = 0.29; CI = 0.16-0.53], Eastern [aOR = 0.12; CI = 0.07-0.21], Northern [aOR = 0.29; CI = 0.12-0.66] and Upper East [aOR = 0.17; CI = 0.09-0.31] regions had lower odds of reporting that NHIS is helping pregnant women in accessing health services.

CONCLUSION

To enhance positive perception towards the use of health services among pregnant women, non-subscribers need to be encouraged to enrol on the NHIS. Together with non-governmental organizations dedicated to maternal and child health issues, the Ghana Health Service's Maternal and Child Health Unit could strengthen efforts to educate pregnant women on the importance of NHIS in maternity care.

National level data analysis of facial lacerations in Korea using the National Health Insurance Service (NHIS) database

No national epidemiological investigations have been conducted recently regarding facial lacerations. The study was performed using the data of 3,634,229 people during the 5-year period from 2014 to 2018 archived by the National Health Information Database (NHID) of the Health Insurance Review and Assessment Service. Preschool and children under 10 years old accounted for about one-third of patients. Facial lacerations were concentrated in the "T-shaped" area, which comprised forehead, nose, lips, and the perioral area. The male to female ratio for all study subjects was 2.16:1. Age and gender are significantly related with each other (P < .001). Mean hospital stays decreased, and numbers of outpatient department visits per patient were highest for hospitals and lowest for health agencies. Over the study period, hospital costs per patient in tertiary and general hospitals increased gradually. Preschool and school-aged children are vulnerable to trauma. Male patients outnumbered female patients by a factor of more than 2. The "T-shaped'" area around forehead is vulnerable to injury. Total cost of medical care benefits per patient in tertiary hospitals was about 7 times on average than in health agencies. Regarding functional, behavioral, and aesthetic outcomes, more attention should be paid to epidemiologic data and hospital costs for facial lacerations.

Effects of a DPP-4 Inhibitor and RAS Blockade on Clinical Outcomes of Patients with Diabetes and COVID-19

BACKGROUND

Dipeptidyl peptidase-4 inhibitor (DPP-4i) and renin-angiotensin system (RAS) blockade are reported to affect the clinical course of coronavirus disease 2019 (COVID-19) in patients with diabetes mellitus (DM).

METHODS

As of May 2020, analysis was conducted on all subjects who could confirm their history of claims related to COVID-19 in the National Health Insurance Review and Assessment Service (HIRA) database in Korea. Using this dataset, we compared the short-term prognosis of COVID-19 infection according to the use of DPP-4i and RAS blockade. Additionally, we validated the results using the National Health Insurance Service (NHIS) of Korea dataset.

RESULTS

Totally, data of 67,850 subjects were accessible in the HIRA dataset. Of these, 5,080 were confirmed COVID-19. Among these, 832 subjects with DM were selected for analysis in this study. Among the subjects, 263 (31.6%) and 327 (39.3%) were DPP4i and RAS blockade users, respectively. Thirty-four subjects (4.09%) received intensive care or died. The adjusted odds ratio for severe treatment among DPP-4i users was 0.362 (95% confidence interval [CI], 0.135 to 0.971), and that for RAS blockade users was 0.599 (95% CI, 0.251 to 1.431). These findings were consistent with the analysis based on the NHIS data using 704 final subjects. The adjusted odds ratio for severe treatment among DPP-4i users was 0.303 (95% CI, 0.135 to 0.682), and that for RAS blockade users was 0.811 (95% CI, 0.391 to 1.682).

CONCLUSION

This study suggests that DPP-4i is significantly associated with a better clinical outcome of patients with COVID-19.

The COVID-19 pandemic: impact on NHS England PET-CT services and lessons learnt

PURPOSE

The purpose of the study was to examine the impact of the first wave of COVID-19 on National Health Service (NHS) 18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET-CT) scanning activity across England.

METHODS

Monthly FDG PET-CT scanning activity was collected from 41/48 NHS England provider sites. Data from 31/41 sites were stratified by nononcology/oncology, cancer type, with lung cancer and lymphoma split into specific indications, turn-around times and delays due to radiotracer.

RESULTS

In April and May 2020, a 32 and 31% decrease in activity was observed, a larger decrease for noncancer compared with cancer FDG PET-CT. In June 2020, activity started to recover with 6% fewer scans recorded compared with June 2019. Of the six most common indications, lung and oesophageal cancer had the largest decrease in activity and slowest recovery. Lymphoma and melanoma showed the smallest decrease and fastest recovery. Lung cancer scans for initial diagnosis/staging saw the largest fall and slowest recovery compared with scans for known lung cancer. There was no percentage increase in overall turn-around time compared with the same months in 2019, and no increase in turn-around time of more than 7 working days due to FDG supply during April and May 2020 compared with the 3 previous months.

CONCLUSIONS

There is no correlation between FDG PET-CT activity (fall and recovery) in England and the ability to provide the service by NHS England. It most likely reflects a combination of changes in health-seeking behaviour, NHS health policy and a decrease in the use of investigations that carry a high risk of COVID-19 transmission.

High waist circumference rather than high body mass index may be a predictive risk factor for the longer disease duration of chronic spontaneous urticaria

In a previous study, we found that higher waist circumference (WC) and higher body mass index (BMI) both increase the risk of chronic spontaneous urticaria (CSU). The aim of this study was to determine whether WC and BMI also increase the duration of CSU. We used multivariable Cox proportional hazards models to determine the hazard ratio (HR) for longer disease duration (longer than 3 years) according to WC and BMI. A total of 52,667 subjects were enrolled and their mean age was 54.5. After adjustments for other confounding variables the high WC/high BMI group had 1.062 times higher HR (95% CI, 1.028-1.098) than the normal WC/normal BMI group. Interestingly, the high WC/normal BMI group showed a significantly higher HR (1.053; 95% CI, 1.008-1.101) than the normal WC/normal BMI group, but not the normal WC/high BMI group (0.998; 95% CI, 0.951-1.046). Taken together, our results suggest that high WC rather than high BMI is a predictive risk factor for the longer disease duration of CSU.

District division administrative disaggregation data framework for monitoring leaving no one behind in the National Health Insurance Fund of Sudan: achieving sustainable development goals in 2030

BACKGROUND

The aim of this study is to monitor the concept of 'leaving no one behind' in the Sustainable Development Goals (SDGs) to track the implications of the mobilization of health care resources by the National Health Insurance Fund (NHIF) of Sudan.

METHODS

A cross-sectional study was used to monitor 'leaving no one behind' in NHIF by analyzing the secondary data of the information system for the year 2016. The study categorized the catchment areas of health care centers (HCCS) according to district administrative divisions, which are neighborhood, subdistrict, district, and zero. The District Division Administrative Disaggregation Data (DDADD) framework was developed and investigated with the use of descriptive statistics, maps of Sudan, the Mann-Whitney test, the Kruskal-Wallis test and health equity catchment indicators. SPSS ver. 18 and EndNote X8 were also used.

RESULTS

The findings show that the NHIF has mobilized HCCs according to coverage of the insured population. This mobilization protected the insured poor in high-coverage insured population districts and left those living in very low-coverage districts behind. The Mann-Whitney test presented a significant median difference in the utilization rate between catchment areas (P value < 0.001). The results showed that the utilization rate of the insured poor who accessed health care centers by neighborhood was higher than that of the insured poor who accessed by more than neighborhood in each state. The Kruskal-Wallis test of the cost of health care services per capita in each catchment area showed a difference (P value < 0.001) in the median between neighborhoods. The cost of health care services in low-coverage insured population districts was higher than that in high-coverage insured population districts.

CONCLUSION

The DDADD framework identified the inequitable distribution of health care services in low-density population districts leaves insured poor behind. Policymakers should restructure the equation of health insurance schemes based on equity and probability of illness, to distribute health care services according to needs and equity, and to remobilize resources towards districts left behind.

No gain in pain: psychological well-being, participation, and wages in the BHPS

Accounting for endogeneity, unobserved heterogeneity, and sample selection in an unified framework, we investigate the effect of psychological well-being on wages and labour market participation using a panel from the British Household Panel Survey. We find the effect of psychological well-being on labour market outcomes to differ across gender. In particular, psychological distress significantly reduces participation across genders, but, conditional on participation, has a significant negative effect on hourly wages only in the female sample.

The incidence of malignant brain tumors is increased in patients with obstructive sleep apnea: A national health insurance survey

The association between obstructive sleep apnea (OSA) and malignant brain tumors has yet to be fully investigated. Therefore, the purpose of this study was to elucidate the effect of OSA on brain tumor incidence based on the Korea National Health Insurance Service (KNHIS) dataset. The KNHIS data between 2007 and 2014 were analyzed, and the primary endpoint was newly diagnosed malignant brain tumor. A total of 198,574 subjects aged ≥ 20 years with newly diagnosed OSA were enrolled in the study, and 992,870 individuals were selected as a control group based on propensity score matching (PSM) by gender and age. The average follow-up duration was 4.8 ± 2.3 years. The hazard ratios (HRs) for brain tumor for patients with OSA were 1.78 (95% confidence interval [CI]: 1.42-2.21) in Model 1 (not adjusted with any covariate) and 1.67 (95% CI: 1.34-2.09) in Model 2 (adjusted for income level, diabetes, hypertension, dyslipidemia, and COPD). In subgroup analysis by gender, the odds ratios (OR) of OSA were 1.82 (95% CI: 1.41-2.33) in men and 1.26 (95% CI: 0.74-2.03) in women. The ORs were 1.97 (95% CI: 1.15-3.24) in the older (age ≥ 65 years) group, 1.66 (95% CI: 1.25-2.17) in the middle-aged (40 ≤ age < 65 years) group, and 1.41 (0.78-2.44) in the young (20 ≤ age < 40 years) group. In conclusion, OSA may increase the incidence of brain tumors.

Ethnic disparities in receiving benefits for disability following postpartum mental illness during first two years after delivery: an Israeli nationwide study

BACKGROUND

Despite relatively high rates of Postpartum Depression (PPD), little is known about the granting of social security benefits to women who are disabled as a result of PPD or of other postpartum mood and anxiety disorders (PMAD). This study aims to identify populations at risk for underutilization of social security benefits due to PMAD among Israeli women, with a focus on ethnic minorities.

METHODS

This retrospective cohort study is based on the National Insurance Institute (NII) database. The study population included a simple 10% random sample of 79,391 female Israeli citizens who gave birth during 2008-2016 (these women delivered a total of 143,871 infants during the study period), and who had not been eligible for NII mental health disability benefits before 2008. The dependent variable was receipt of Benefit Entitlement (BE) due to mental illness within 2 years following childbirth. Maternal age at delivery, population group, Socio-Economic Status (SES), family status, employment status of the mother and her spouse, and infant mortality were the independent variables. Left truncation COX proportional hazard model with time-dependent variables was used, and birth number served as a time discrete variable.

RESULTS

Bedouin and Arab women had significantly lower likelihood of BE (2.6 times lower and twice lower) compared with other ethnic groups (HR = 0.38; 95% CI: 0.26-0.56; HR = 0.47; 95% CI: 0.37-0.60 respectively). The probability of divorced or widowed women for BE was significantly higher compared to those living with a spouse (HR = 3.64; 95% CI: 2.49-5.33). Lack of employment was associated with higher likelihood of BE (HR = 1.54; 95% CI: 1.30-1.82). Income had a dose-response relationship with BE in multivariable analysis: lower income was associated with the nearly four-fold greater probability compared to the highest income quartile (HR = 3.83; 95% CI: 2.89-5.07).

CONCLUSIONS

Despite the exceptionally high prevalence of PMAD among ethnic minorities, Bedouins and Arabs had lowest likelihood of Benefit Entitlement. In addition to developing programs for early identification of postpartum emotional disorders among unprivileged ethnic groups, awareness regarding entitlement to a mental health disability allowance among ethnic minorities should be improved.

National pharmacological treatment trends for ankylosing spondylitis in South Korea: A national health insurance database study

No studies of the current status of treatment options are available for ankylosing spondylitis (AS) patients in South Korea. This study assesses the current status of AS treatment trends using a nationwide database. This study was conducted using a Korean National Health Insurance System (KNHIS) dataset from 2006 to 2016. We randomly extracted 50% of the total number of patients registered as As patients in the KNHIS. The distribution of the number of patients according to age and gender was analyzed each year. The types and combination methods of drugs used during the study period were estimated yearly. Between 2006 and 2016, the number of AS patients increased linearly by an average of 9% annually, 6372 in 2006 to 15188 in 2016. The study found that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) was the most commonly prescribed pharmacological treatment option, followed by disease-modifying anti-rheumatic drugs (DMARDs) and then biologics. Biologics such as tumor necrosis factor alpha (TNF-α) inhibitors increased from 10% to 35% consistently for 10 years. In terms of combination therapy, DMARDs + NSAIDs accounted for almost 90% of treatments in 2006, but decreased by 65% in 2016. The use of biologics and NSAIDs increased from 3% to 28%. Prescriptions for dual therapies and mono therapies largely dominated prescription habits, accounted for up to approximately 80% of treatments. Among 10- to 14-year-old patients, there was no triple therapy, dual and triple therapies decreased gradually for those 60 and older, and the ratio of conservative treatments has increased. This study shows how South Korea reflects changes in AS treatment trends, along with the emergence of TNF-α inhibitors that are effective in treating AS. Research on clinical outcomes for AS treatments will be needed on following these drug changes.

National trends in incidence, mortality, hospitalizations, and expenditures for pemphigus in Taiwan

BACKGROUND

Data on trends in epidemiological characteristics and economic burden of pemphigus are scarce.

OBJECTIVE

To describe national trends in pemphigus' incidence, mortality, hospitalizations, and expenditures between 2003 and 2015 in Taiwan.

METHODS

This nationwide study used the Taiwan National Health Insurance Research Database to identify pemphigus patients from 2003 to 2015. Annual incidence, prevalence, healthcare utilization, and expenditure trends were calculated and analyzed.

RESULTS

Pemphigus' incidence increased significantly from 3.19 to 4.70 per million person-years in 2003-2010 but fluctuated in 2011-2015. Pemphigus patients had higher mortality and care costs. Medical utilization and expenditure declined for pemphigus inpatients and outpatients. Systemic corticosteroid use decreased, but mortality remained stable.

CONCLUSION

The health expense reduction for pemphigus was mainly attributed to decreased utilization, length of stay, and inpatient costs. The persistently elevated mortality rate highlights an unmet need in pemphigus therapy.

Transmission patterns of COVID-19 in the mainland of China and the efficacy of different control strategies: a data- and model-driven study

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak has seriously endangered the health and lives of Chinese people. In this study, we predicted the COVID-19 epidemic trend and estimated the efficacy of several intervention strategies in the mainland of China.

METHODS

According to the COVID-19 epidemic status, we constructed a compartmental model. Based on reported data from the National Health Commission of People's Republic of China during January 10-February 17, 2020, we estimated the model parameters. We then predicted the epidemic trend and transmission risk of COVID-19. Using a sensitivity analysis method, we estimated the efficacy of several intervention strategies.

RESULTS

The cumulative number of confirmed cases in the mainland of China will be 86 763 (95% CI: 86 067-87 460) on May 2, 2020. Up until March 15, 2020, the case fatality rate increased to 6.42% (95% CI: 6.16-6.68%). On February 23, 2020, the existing confirmed cases reached its peak, with 60 890 cases (95% CI: 60 350-61 431). On January 23, 2020, the effective reproduction number was 2.620 (95% CI: 2.567-2.676) and had dropped below 1.0 since February 5, 2020. Due to governmental intervention, the total number of confirmed cases was reduced by 99.85% on May 2, 2020. Had the isolation been relaxed from February 24, 2020, there might have been a second peak of infection. However, relaxing the isolation after March 16, 2020 greatly reduced the number of existing confirmed cases and deaths. The total number of confirmed cases and deaths would increase by 8.72 and 9.44%, respectively, due to a 1-day delayed diagnosis in non-isolated infected patients. Moreover, if the coverage of close contact tracing was increased to 100%, the cumulative number of confirmed cases would be decreased by 88.26% on May 2, 2020.

CONCLUSIONS

The quarantine measures adopted by the Chinese government since January 23, 2020 were necessary and effective. Postponing the relaxation of isolation, early diagnosis, patient isolation, broad close-contact tracing, and strict monitoring of infected persons could effectively control the COVID-19 epidemic. April 1, 2020 would be a reasonable date to lift quarantine in Hubei and Wuhan.

Educational inequalities in mortality amenable to healthcare. A comparison of European healthcare systems

BACKGROUND

Educational inequalities in health and mortality in European countries have often been studied in the context of welfare regimes or political systems. We argue that the healthcare system is the national level feature most directly linkable to mortality amenable to healthcare. In this article, we ask to what extent the strength of educational differences in mortality amenable to healthcare vary among European countries and between European healthcare system types.

METHODS

This study uses data on mortality amenable to healthcare for 21 European populations, covering ages 35-79 and spanning from 1998 to 2006. ISCED education categories are used to calculate relative (RII) and absolute inequalities (SII) between the highest and lowest educated. The healthcare system typology is based on the latest available classification. Meta-analysis and ANOVA tests are used to see if and how they can explain between-country differences in inequalities and whether any healthcare system types have higher inequalities.

RESULTS

All countries and healthcare system types exhibited relative and absolute educational inequalities in mortality amenable to healthcare. The low-supply and low performance mixed healthcare system type had the highest inequality point estimate for the male (RII = 3.57; SII = 414) and female (RII = 3.18; SII = 209) population, while the regulation-oriented public healthcare systems had the overall lowest (male RII = 1.78; male SII = 123; female RII = 1.86; female SII = 78.5). Due to data limitations, results were not robust enough to make substantial claims about typology differences.

CONCLUSIONS

This article aims at discussing possible mechanisms connecting healthcare systems, social position, and health. Results indicate that factors located within the healthcare system are relevant for health inequalities, as inequalities in mortality amenable to medical care are present in all healthcare systems. Future research should aim at examining the role of specific characteristics of healthcare systems in more detail.

Construction and Use of Body Weight Measures from Administrative Data in a Large National Health System: A Systematic Review

OBJECTIVE

Administrative data are increasingly used in research and evaluation yet lack standardized guidelines for constructing measures using these data. Body weight measures from administrative data serve critical functions of monitoring patient health, evaluating interventions, and informing research. This study aimed to describe the algorithms used by researchers to construct and use weight measures.

METHODS

A structured, systematic literature review of studies that constructed body weight measures from the Veterans Health Administration was conducted. Key information regarding time frames and time windows of data collection, measure calculations, data cleaning, treatment of missing and outlier weight values, and validation processes was collected.

RESULTS

We identified 39 studies out of 492 nonduplicated records for inclusion. Studies parameterized weight outcomes as change in weight from baseline to follow-up (62%), weight trajectory over time (21%), proportion of participants meeting weight threshold (46%), or multiple methods (28%). Most (90%) reported total time in follow-up and number of time points. Fewer reported time windows (54%), outlier values (51%), missing values (34%), or validation strategies (15%).

CONCLUSIONS

A high variability in the operationalization of weight measures was found. Improving methods to construct clinical measures will support transparency and replicability in approaches, guide interpretation of findings, and facilitate comparisons across studies.

Factors associated with patient payments exceeding National Health Insurance fees and out-of-pocket payments in Lao PDR

BACKGROUND

Attaining universal health coverage is a target in the Sustainable Development Goals. In Lao PDR, to achieve universal health coverage, the government is implementing a national insurance scheme, initially targeting the informal sector.

OBJECTIVE

The purpose was to assess: i) the percentage of NHI patients who paid above the scheduled amount, based on individual billing payment; and ii) the factors related to overpayment.

METHODS

Descriptive cross-sectional study based on a structured questionnaire administered at health facilities in face-to-face interviews with 1,850 patients in six provinces.

RESULTS

All 1,850 participants worked in the informal sector. Of these, 78.8% of respondents (77.9% of in-patients; 79.5% of out-patients) made co-payments or were exempted from. Factors associated with in-patients paying above the scheduled fee were living in the province and district (OR = 2.8; 95%CI 1.2 to 6.3); not having documents with them (OR = 21.2; 95%CI 5.6 to 80.3); or not having documents (OR: 7.8; 95% CI 2.1 to 28.6). Significant factors associated with additional costs for out-patients were level of facility used at the provincial hospital (OR:1.4; 95% CI 1.1 to 1.9); older age (OR = 2.2; 95%CI 1.5 to 3.1); living in the province and district (OR = 2.3; 95%CI 1.5 to 3.7); living more than 5 km from the facility (OR = 1.4; 95%CI 1.1 to 1.9); buying medicine or supplies outside of the health facility (OR: 5.6; 95% CI 3.1 to 10.2); not bringing documents (OR:9.1; 95% CI 6.1 to 13.5), not having the right documents (OR: 8.9; 95% CI 5.4 to 14.8).

CONCLUSIONS

A number of patients paid above scheduled fee rates, which may deter people from utilising services when needing them. There is a need for increased understanding of the benefits of the national insurance scheme among patients and healthcare staff.

Inequality in Life Expectancy in Korea according to Various Categorizations of the National Health Insurance Premiums as a Marker of Income

The purpose of this study was to examine the degree to which the magnitude of income inequality in life expectancy according to different categorization across beneficiary types under the National Health Insurance Service (NHIS) in Korea. We used population and death data in 2017 from the National Health Information Database of the NHIS. Income quintile groups were classified in four ways according to beneficiary type (employee insured, self-employed insured, and Medical Aid beneficiaries). Standard life table procedures were used to calculate life expectancy. The life expectancy gap between the lowest and highest income quintiles was the largest when the entire population was divided into quintiles without distinguishing among types of beneficiaries. In conclusion, we suggest that income quintile indicators in NHIS data, measured without distinguishing among types of beneficiaries, may best represent the magnitude of health inequalities in Korean society. This indicator could be used for future research on health inequalities, as well as for monitoring health inequalities in Korea.

Cost-effectiveness of a Stepwise Approach vs Standard Care for Diabetes Prevention in India

IMPORTANCE

A stepwise approach that includes screening and lifestyle modification followed by the addition of metformin for individuals with high risk of diabetes is recommended to delay progression to diabetes; however, there is scant evidence regarding whether this approach is cost-effective.

OBJECTIVE

To estimate the cost-effectiveness of a stepwise approach in the Diabetes Community Lifestyle Improvement Program.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation study included 578 adults with impaired glucose tolerance, impaired fasting glucose, or both. Participants were enrolled in the Diabetes Community Lifestyle Improvement Program, a randomized clinical trial with 3-year follow-up conducted at a diabetes care and research center in Chennai, India.

INTERVENTIONS

The intervention group underwent a 6-month lifestyle modification curriculum plus stepwise addition of metformin; the control group received standard lifestyle advice.

MAIN OUTCOMES AND MEASURES

Cost, health benefits, and incremental cost-effectiveness ratios (ICERs) were estimated from multipayer (including direct medical costs) and societal (including direct medical and nonmedical costs) perspectives. Costs and ICERs were reported in 2019 Indian rupees (INR) and purchasing power parity-adjusted international dollars (INT $).

RESULTS

The mean (SD) age of the 578 participants was 44.4 (9.3) years, and 364 (63.2%) were men. Mean (SD) body mass index was 27.9 (3.7), and the mean (SD) glycated hemoglobin level was 6.0% (0.5). Implementing lifestyle modification and metformin was associated with INR 10 549 (95% CI, INR 10 134-10 964) (INT $803 [95% CI, INT $771-834]) higher direct costs; INR 5194 (95% CI, INR 3187-INR 7201) (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2% (95% CI, 1.9% to 18.5%), and an incremental gain of 0.099 (95% CI, 0.018 to 0.179) quality-adjusted life-years per participant. From a multipayer perspective (including screening costs), mean ICERs were INR 1912 (INT $145) per 1 percentage point diabetes risk reduction, INR 191 090 (INT $14 539) per diabetes case prevented and/or delayed, and INR 196 960 (INT $14 986) per quality-adjusted life-year gained. In the scenario of a 50% increase or decrease in screening and intervention costs, the mean ICERs varied from INR 855 (INT $65) to INR 2968 (INT $226) per 1 percentage point diabetes risk reduction, from INR 85 495 (INT $6505) to INR 296 681 (INT $22 574) per diabetes case prevented, and from INR 88 121 (INT $6705) to INR 305 798 (INT $23 267) per quality-adjusted life-year gained.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added.

A study on the impact of poor medication adherence on health status and medical expense for diabetes mellitus patients in Taiwan: A longitudinal panel data analysis

Medication adherence plays an important role in disease management, especially for diabetes. The aim of this study was to examine the impacts of demographic characteristics on medication nonadherence and the impacts of nonadherence on both health status and medical expenses for diabetic patients in Taiwan.A total of 1 million diabetes mellitus patients were randomly selected from the National Health Insurance Research Database between January 1, 2000 and December 31, 2004. All records with missing values and those for participants under 18 years of age were then deleted. Because many patients had multiple clinical visit records, all records within the same calendar year were summarized into 1 single record for each person. This pre-processing resulted in 14,602 total patients with a combined 73,010 records over the course of 5 years. Generalized estimating equation models were then constructed to investigate the effects of demographic characteristics on medication nonadherence and the effects of nonadherence on patient health status and medical expenses. The demographic characteristics examined for each patient include gender, age, residential area, and socioeconomic status.Our analysis of how demographic variables impacted nonadherence revealed that elderly patients exhibited better overall medication adherence, but that male patients exhibited poorer medication adherence than female patients. Next, our analysis of how nonadherence impacted health status revealed that patients who exhibited medication nonadherence had poorer health status than patients with proper medication adherence. Finally, our analysis of how nonadherence impacted medical expenses revealed that patients who exhibited medication nonadherence incurred more medical expenses than those who exhibited proper medication adherence.This study's empirical results corroborate the general relationships expressed in the current literature regarding medication nonadherence. However, this study's results were statistically more reliable and revealed the precise impact on health status in terms of the Charlson comorbidity index and increased annual medical expenses. This indicates the need to improve patient attitudes toward medication adherence, which can have substantial effects both medically and economically.

Differences in realized access to healthcare among newly arrived refugees in Germany: results from a natural quasi-experiment

BACKGROUND

Germany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Newly arrived refugees whose asylum claim is still being processed are initially excluded from the SHI. Instead, their entitlements are restricted and parallel access models have been implemented. We assessed differences in realized access of healthcare services between these access models.

METHODS

In Germany's largest federal state, North Rhine-Westphalia, two different access models have been implemented in the 396 municipalities: the healthcare voucher (HcV) model and the electronic health card (eHC) model. As refugees are quasi-randomly assigned to municipalities, we were able to realize a natural quasi-experiment including all newly assigned refugees from six municipalities (three for each model) in 2016 and 2017. Using claims data, we compared the standardized incidence rates (SIR) of specialist services use, emergency services use, and hospitalization due to ambulatory care sensitive conditions (ACSC) between both models. We indirectly standardized utilization patterns first for age and then for the sex.

RESULTS

SIRs of emergency use were higher in municipalities with HcV (ranging from 1.41 to 2.63) compared to emergency rates in municipalities with eHC (ranging from 1.40 to 1.71) and differed significantly from the expected rates derived from official health reporting. SIRs of emergency and specialist use in municipalities with eHC converged with the expected rates over time. There were no significant differences in standardized hospitalization rates for ACSC.

CONCLUSION

The results suggest that the eHC model is slightly better able to provide refugees with SHI-like access to specialist services and goes along with lower utilization of emergency services compared to the HcV model. No difference between the models was found for hospitalizations due to ACSC. Results might be slightly biased due to incompletely documented service use and due to (self-) selection on the level of municipalities with municipalities interested in facilitating access showing more interest in joining the project.

Risk Factors for Intraocular Lens Dislocation After Phacoemulsification: A Nationwide Population-Based Cohort Study

PURPOSE

Few studies have measured the incidence and risk factors of intraocular lens (IOL) dislocation in the total population. We investigate the risk factors for IOL dislocation in a nationwide Korean cohort.

DESIGN

Retrospective cohort study.

METHODS

National data on 2,162,191 subjects who underwent cataract surgery were collected from the Health Insurance Review and Assessment service database of health claims from 2009 to 2016. The Health Insurance Review and Assessment database was used to identify potential risk factors for IOL dislocation, including age, sex, and various pre- and postoperative ophthalmic conditions. The hazard ratios (HRs) and confidence intervals (CIs) of these risk factors were assessed with a multivariable-adjusted Cox regression model.

RESULTS

IOL dislocation occurred in 15,170 patients (0.7%) in the cataract surgery cohort (2,162,191 patients). The incidence rate of IOL dislocation peaked at 40-50 years of age, although the mean age of IOL dislocation was 65.25 ± 10.81 years. The average male:female ratio was 1.8. The adjusted HR for IOL dislocation in patients with partial vitrectomy was 11.93 (95% CI 10.95-12.99; P < .0001). Posterior capsulotomy performed within 1 year after the cataract surgery significantly decreased IOL dislocation, with an adjusted HR of 0.48 (95% CI 0.44-0.51; P < .0001).

CONCLUSIONS

IOL dislocation tended to occur in young males. Anterior vitrectomy was a significant risk factor for IOL dislocation, while posterior capsulotomy after surgery was associated with a decreased risk of IOL dislocation.

Statin use increased new-onset diabetes in hypercholesterolemic individuals: Data from the Korean National Health Insurance Service-National Health Screening Cohort database (NHIS-HEALS)

AIM

We investigated the association between statin use and new-onset diabetes (NODM) in Korean adults with hypercholesterolemia.

METHODS

This study performed based on data from the National Health Insurance Service-National Health Screening Cohort for the years from 2002 to 2015. Statin users classified as high- or low- users according to medication possession ratio. Statin non-users consisted of hypercholesterolemic participants who never used statin over the entire follow-up period. 21,469 participants (10,880 statin users, 10,589 statin non-users) with a median follow-up period of 12.5 years were included. We estimated the NODM risk based on the survival analyses. In particular, to adjust for confounding effects, we considered Cox proportional hazards regression models over three stages.

RESULTS

Compared to non-users, statin users had a significantly higher risk for NODM. The fully adjusted hazard ratios (aHRs) (95% confidential intervals [95% CIs]) of statin users for NODM were 1.43 (1.31-1.57) in men, and 1.86 (1.66-2.10) in women, respectively after adjusted confounding factors including age and lifestyle factors. Compared to high-users, aHRs (95% CIs) of low-users for NODM were 1.16 (1.03-1.30) and 1.28 (1.16-1.43) in men and women, respectively.

CONCLUSIONS

In hypercholesterolemic patients, statin users have a higher risk of NODM than non-users.

Performance management in primary healthcare: Nurses' experiences

BACKGROUND

The use of the performance management (PM) system is highly contested by public servants in South Africa, although its value as essential to the appraisal and management of staff is undeniable.

OBJECTIVES

The aim of this study was to explore nurses' perceptions and experiences of the PM system at primary healthcare (PHC) facilities in relation to the current health system's reforms.

METHOD

An exploratory, descriptive and qualitative design was utilised. Participants were selected through purposive sampling. A semi-structured interview tool was used to collect data from 18 nurses in four sub-districts of Dr. Kenneth Kaunda district in the North West province. Data were analysed through thematic analysis.

RESULTS

The findings of this study confirmed that PM is implemented to some extent. However, various loopholes in its implementation threaten the accuracy and transparency of the system and leave it vulnerable to perceived organisational injustice and unfairness, with the objectivity of the system questioned. The limitations of the current PM system revealed by this study include (1) the lack of alignment with current health system reforms towards comprehensive and integrated care that demands person-centred care; (2) the system's usefulness for career progression, performance improvement and rewarding exceptional performance.

CONCLUSION

Performance management is inadequately applied in PHC facilities at district level and needs to be realigned to include the appraisal of key attributes required for the current health system's reforms towards comprehensive and integrated care, including the provision of person-centred care, which is central for responding adequately to South Africa's changing disease profile towards multi-morbidity.

Continuity of Care Is Associated with Medical Costs and Inpatient Days in Children with Cerebral Palsy

Background: Children with cerebral palsy (CP) place a considerable burden on medical costs and add to an increased number of inpatient days in Taiwan. Continuity of care (COC) has not been investigated in this population thus far. Materials and Methods: We designed a retrospective population-based cohort study using Taiwan’s National Health Insurance Research Database. Patients aged 0 to 18 years with CP catastrophic illness certificates were enrolled. We investigated the association of COC index (COCI) with medical costs and inpatient days. We also investigated the possible clinical characteristics affecting the outcome. Results: Over five years, children with CP with low COCI levels had higher medical costs and more inpatient days than did those with high COCI levels. Younger age at CP diagnosis, more inpatient visits one year before obtaining a catastrophic illness certificate, pneumonia, and nasogastric tube use increased medical expenses and length of hospital stay. Conclusions: Improving COC reduces medical costs and the number of inpatient days in children with CP. Certain characteristics also influence these outcomes.

Day Temperature Difference and Aggravation of Low Urinary Tract Symptom in Benign Prostate Hypertrophy Patients in Korea: A National Health Insurance Service-National Cohort-based Study

OBJECTIVE

To investigate the symptom deterioration of patients with benign prostatic hyperplasia (BPH) according to the difference in daily temperature.

PATIENTS AND METHODS

From the National Health Insurance Service database, we collected and analyzed data on patients with BPH in 6 major metropolitan areas in Korea between January 2008 and December 2017. We investigated the rate of emergency room visits as well as the rate of urethral catheter insertion.

RESULTS

In total, 1,446,465 patients were enrolled in this study. When the daily temperature difference was below 4°C, 28.5 patients visited the emergency room daily, while 42.2 patients visited the emergency room daily when the daily temperature difference exceeded 14°C. When the daily temperature difference was more than 14°C, about 48.0% more patients visited the emergency room than when the daily temperature difference was below 4°C. After visiting the emergency room, there were 11.9 patients who had a catheter inserted daily at the daily temperature difference below 4°C. When the daily temperature difference was more than 14°C, the number of catheter insertion cases was 17.8 patients daily, which was 49.2% higher than that of below 4°C. By time, surgery was performed most frequently within 3 months after visiting the emergency room.

CONCLUSION

Day temperature difference appear to be related to the Lower urinary tract symptom of BPH patients.

Artificial intelligence-assisted prediction of preeclampsia: Development and external validation of a nationwide health insurance dataset of the BPJS Kesehatan in Indonesia

Background

We developed and validated an artificial intelligence (AI)-assisted prediction of preeclampsia applied to a nationwide health insurance dataset in Indonesia.

Methods

The BPJS Kesehatan dataset have been preprocessed using a nested case-control design into preeclampsia/eclampsia (n = 3318) and normotensive pregnant women (n = 19,883) from all women with one pregnancy. The dataset provided 95 features consisting of demographic variables and medical histories started from 24 months to event and ended by delivery as the event. Six algorithms were compared by area under the receiver operating characteristics curve (AUROC) with a subgroup analysis by time to the event. We compared our model to similar prediction models from systematically reviewed studies. In addition, we conducted a text mining analysis based on natural language processing techniques to interpret our modeling results.

Findings

The best model consisted of 17 predictors extracted by a random forest algorithm. Nine∼12 months to the event was the period that had the best AUROC in external validation by either geographical (0.88, 95% confidence interval (CI) 0.88–0.89) or temporal split (0.86, 95% CI 0.85–0.86). We compared this model to prediction models in seven studies from 869 records in PUBMED, EMBASE, and SCOPUS. This model outperformed the previous models in terms of the precision, sensitivity, and specificity in all validation sets.

Interpretation

Our low-cost model improved preliminary prediction to decide pregnant women that will be predicted by the models with high specificity and advanced predictors.

Funding

This work was supported by grant no. MOST108-2221-E-038-018 from the Ministry of Science and Technology of Taiwan.

Epidemiology and Prognosis of Pheochromocytoma/Paraganglioma in Korea: A Nationwide Study Based on the National Health Insurance Service

BACKGROUND

Pheochromocytomas and paragangliomas (PPGLs) are rare endocrine tumors originating from chromaffin cells. PPGLs are associated with a high mortality rate and several complications. To date, no epidemiological studies have been conducted on PPGLs in Asia. This study aimed to investigate the epidemiology and prognosis of PPGLs in Korea using nationwide data.

METHODS

Using the National Health Insurance Service Database, subjects with a principal diagnosis of PPGLs on two or more occasions between 2003 and 2014 who satisfied the operational definition of PPGLs were included. Incidence, prevalence, complications, metastasis, and mortality were investigated.

RESULTS

In total, 1048 subjects with a mean age of 47.6±16.1 years were included. There was no sex preponderance. The overall prevalence of PPGLs was 2.13 per 100,000 persons, and the overall age-standardized incidence rate was 0.18 per 100,000 person-years. Malignant PPGLs accounted for 17.7% (185 of 1,048) of cases, and 94 subjects exhibited metastasis at the time of diagnosis. Among initially non-metastatic PPGLs, 9.5% (nine of 954) eventually metastasized after a mean duration of 78.1±41.4 months. The 5-year survival rates for non-metastatic and metastatic PPGLs at diagnosis were 97% and 84%, respectively. Multivariable Cox regression models adjusted for covariates showed that metastatic PPGLs were associated with a 2.40-fold higher risk of mortality than non-metastatic PPGLs (95% confidence interval, 1.38 to 4.17; P=0.002).

CONCLUSION

PPGLs are rare in Korea, and the prognosis of these endocrine tumors varies depending on whether they are benign or malignant. This epidemiological study paves the way for further research on PPGLs.

Why Do Informal Sector Workers Not Pay the Premium Regularly? Evidence from the National Health Insurance System in Indonesia

BACKGROUND

The challenges of universal health coverage (UHC) in developing countries with a significant proportion of the labor force that works in the informal sector include administrative difficulties in recruiting, registering and collecting regular contributions in a cost-effective way. As most developing countries have a limited fiscal space to support the program in the long run, the fiscal sustainability of UHC, such as that in Indonesia, relies heavily on the contributions of its members. The failure of a large proportion of voluntary enrollees/self-enrolled members/informal sector workers (Peserta Mandiri/Pekerja Bukan Penerima Upah [PBPU] members) to pay their premiums may lead to the National Health Insurance System (NHIS) in Indonesia being unable to effectively deliver its services.

OBJECTIVE

This study aims at exploring the important factors that affect the compliance behavior of informal sector workers (PBPU members) in regularly paying their insurance premium. This analysis may be a basis for designing effective measures to encourage payment sustainability in informal sector workers in the NHIS.

METHOD

This study utilizes the survey data collected from three regional offices of the Indonesian Social Security Agency for Health (SSAH), which cover approximately 1210 PBPU members, to understand the relationship between members' characteristics and their compliance behavior regarding the premium payment. We applied an econometric analysis of a logit regression to statistically estimate which factors most affect their compliance behavior in paying the insurance premium.

RESULTS

This study reveals that almost 28% of PBPU members do not pay their insurance premiums in a sustainable way. Our logistic regression statistically confirms that the number of household members, financial hardship, membership in other social protection arrangements, and the utilization of health services are negatively correlated with the compliance rate of informal sector workers in paying their insurance premium. For instance, people who experience financial hardship tend to have a 7.7 percentage point lower probability of routinely paying the premium. In contrast, households that work in agricultural sectors and have income stability, the cost of inpatient care incurred before joining the NHIS, a comprehensive knowledge of the SSAH's services, and the availability of health professionals are all positively correlated with regular premium payment.

CONCLUSION

Although there is no single policy that can ensure that informal sector workers (PBPU members) regularly pay their premiums, this study recommends some policy interventions, including (1) flexibility in applying for a government subsidy for premiums (Penerima Bantuan Iuran [PBI]), especially for people who have financial hardship; (2) an intensive promotion of insurance literacy; (3) expanding the quantity and quality of healthcare services; and (4) tailor-made policies for ensuring the sustainability of premium payments for each regional division.

Trends and risk factors of elderly-onset Crohn’s disease: A nationwide cohort study

BACKGROUND

The incidence of inflammatory bowel disease (IBD) is increasing in Asia. Numerous risk factors associated with IBD development have been investigated.

AIM

To investigate trends and environmental risk factors of Crohn’s disease (CD) diagnosed in persons aged ≥ 40 years in South Korea.

METHODS

Using the National Health Insurance Service database, a total of 14060821 persons aged > 40 years who underwent national health screening in 2009 were followed up until December 2017. Patients with newly diagnosed CD were enrolled and compared with non-CD cohort. CD was identified according to the International Classification of Diseases 10th revision and the rare/intractable disease registration program codes from the National Health Insurance Service database. The mean follow-up periods was 7.39 years. Age, sex, diabetes, hypertension, smoking, alcohol consumption, regular exercise, body mass index, anemia, chronic kidney disease (CKD) and dyslipidemia were adjusted for in the multivariate analysis model.

RESULTS

During the follow-up, 1337 (1.33/100000) patients developed CD. Men in the middle-aged group (40-64 years) had a higher risk than women [adjusted hazard ratio (aHR) 1.46, 95% confidence interval (CI): 1.29-1.66]; however, this difference tended to disappear as the age of onset increases. In the middle-aged group, patients with a history of smoking [aHR 1.46, 95%CI: 1.19-1.79) and anemia (aHR 1.85, 95%CI: 1.55-2.20) had a significantly higher CD risk. In the elderly group (age, ≥ 65 years), ex-smoking and anemia also increased the CD risk (aHR 1.68, 95%CI: 1.22-2.30) and 1.84 (95%CI: 1.47-2.30, respectively). Especially in the middle-aged group, those with CKD had a statistically elevated CD risk (aHR 1.37, 95%CI: 1.05-1.79). Alcohol consumption and higher body mass index showed negative association trend with CD incidence in both of the age groups. [Middle-aged: aHR 0.77 (95%CI: 0.66-0.89) and aHR 0.73 (95%CI: 0.63-0.84), respectively] [Elderly-group: aHR 0.57 (95%CI: 0.42-0.78) and aHR 0.84 (95%CI 0.67-1.04), respectively]. For regular physical activity and dyslipidemia, negative correlation between CD incidences was proved only in the middle-aged group [aHR 0.88 (95%CI: 0.77-0.89) and aHR 0.81 (95%CI: 0.68-0.96), respectively].

CONCLUSION

History of cigarette smoking, anemia, underweight and CKD are possible risk factors for CD in Asians aged > 40 years.

Whether productive authors using the national health insurance database also achieve higher individual research metrics: A bibliometric study

BACKGROUND

Many researchers use the National Health Insurance Research Database (HIRD) to publish medical papers and gain exceptional outputs in academics. Whether they also obtain excellent citation metrics remains unclear.

METHODS

We searched the PubMed database (http://www.ncbi.nlm.nih.gov/pubmed) using the terms Taiwan and HIRD. We then downloaded 1997 articles published from 2012 to 2016. An authorship-weighted scheme (AWS) was applied to compute coauthor partial contributions from the article bylines. Both modified x-index and author impact factor (AIF) proved complementary to Hirsch's h-index for calculating individual research achievements (IRA). The metrics from 4684 authors were collected for comparison. Three hundred eligible authors with higher x-indexes were located and displayed on Google Maps dashboards. Ten separate clusters were identified using social network analysis (SNA) to highlight the research teams. The bootstrapping method was used to examine the differences in metrics among author clusters. The Kano model was applied to classify author IRAs into 3 parts.

RESULTS

The most productive author was Investigator#1 (Taichung City, Taiwan), who published 149 articles in 2015 and included 803 other members in his research teams. The Kano diagram results did not support his citation metrics beyond other clusters and individuals in IRAs.

CONCLUSION

The AWS-based bibliometric metrics make individual weighted research evaluations possible and available for comparison. The study results of productive authors using HIRD did not support the view that higher citation metrics exist in specific disciplines.

Natural History of Acromegaly: Incidences, Re-operations, Cancers, and Mortality Rates in a National Cohort

BACKGROUND

Acromegaly is so rare that its natural history, including incidence, risk of cancers, and mortality rates, remains elusive. This natural study utilized a nationwide database to provide a better understanding of acromegaly's disease course.

METHODS

A cohort of 1,195 acromegaly patients were identified and followed-up from 1997 to 2013. Incidence, operation, and re-operation rates were calculated. Excessive mortality and cancer risk related to acromegaly were estimated by standardized mortality ratio (SMR) and standardized incidence ratio (SIR).

RESULTS

The incidence was 2.78 per million-person-years, with little gender predominance (female vs. male, 49.5 vs. 50.5%, respectively). There was female predominance only among 50 and 60 year-olds (incidence rate ratio: 1.37 and 1.43, p < 0.001 and p = 0.002). Among them, 673 (56.3%) had hypophysectomy surgery, and the young-onset (<40 years) patients had more re-operations (15.5%, p = 0.01). The overall mortality rate was 22.3 per 1,000 person-years, with a median survival of 4.67 years (with no gender differences, p = 0.38). The overall SMR of acromegaly patients was 1.41, and the onset-age-specific SMRs of the early- and middle-onset patients were higher than for those with late-onset. There were 87 newly diagnosed cancers in the cohort, with an incidence rate of 10.6 per 1,000 person-years (median 5.4 years). The overall SIR of cancers was 1.91, and there were no differences among gender, onset-age, and disease duration (all SIR >1, approximately 2).

CONCLUSION

Acromegaly is associated with an excessive risk of mortality and two-fold higher risk of cancers. Patients with acromegaly should be managed appropriately after the diagnosis.