Disparities in cause-specific mortality by health insurance type and premium: evidence from Korean NHIS-HEALS cohort study, 2002-2019.

BACKGROUND: Although one's socioeconomic status affects health outcomes, limited research explored how South Korea's National Health Insurance (NHI) system affects mortality rates. This study investigated whether health insurance type and insurance premiums are associated with mortality. METHODS: Based on the National Health Insurance Service-Health Screening cohort, 246,172 men and 206,534 women aged ≥ 40 years at baseline (2002-2003) were included and followed until 2019. Health insurance type was categorized as employee-insured (EI) or self-employed-insured (SI). To define low, medium, and high economic status groups, we used insurance premiums at baseline. Death was determined using the date and cause of death included in the cohort. Cox proportional hazard models were used to analyze the association between insurance factors and the overall and cause-specific mortality. RESULTS: The SI group had a significantly higher risk of overall death compared to the EI group (adjusted hazard ratio (HR) [95% confidence interval]: 1.13 [1.10-1.15] for men and 1.18 [1.15-1.22] for women), after adjusting for various factors. This trend extended to death from the five major causes of death in South Korea (cancer, cardiovascular disease, cerebrovascular disease, pneumonia, and intentional self-harm) and from external causes, with a higher risk of death in the SI group (vs. the EI group). Further analysis stratified by economic status revealed that individuals with lower economic status faced higher risk of overall death and cause-specific mortality in both sexes, compared to those with high economic status for both health insurance types. CONCLUSION: This nationwide study found that the SI group and those with lower economic status faced higher risk of overall mortality and death from the five major causes in South Korea. These findings highlight the potential disparities in health outcomes within the NHI system. To address these gaps, strategies should target risk factors for death at the individual level and governments should incorporate such strategies into public health policy development at the population level. TRIAL REGISTRATION: This study was approved by the Institutional Review Board of Chungbuk National University Hospital (CBNUH-202211-HR-0236) and adhered to the principles of the Declaration of Helsinki (1975).

Cost-Effectiveness Analysis of Home-Based Hospice-Palliative Care for Terminal Cancer Patients.

Purpose: We compared cost-effectiveness parameters between inpatient and home-based hospice-palliative care services for terminal cancer patients in Korea. Methods: A decision-analytic Markov model was used to compare the cost-effectiveness of hospice-palliative care in an inpatient unit (inpatient-start group) and at home (home-start group). The model adopted a healthcare system perspective, with a 9-week horizon and a 1-week cycle length. The transition probabilities were calculated based on the reports from the Korean National Cancer Center in 2017 and Health Insurance Review & Assessment Service in 2020. Quality of life (QOL) was converted to the quality-adjusted life week (QALW). Modeling and cost-effectiveness analysis were performed with TreeAge software. The weekly medical cost was estimated to be 2,481,479 Korean won (KRW) for inpatient hospice-palliative care and 225,688 KRW for home-based hospice-palliative care. One-way sensitivity analysis was used to assess the impact of different scenarios and assumptions on the model results. Results: Compared with the inpatient-start group, the incremental cost of the home-start group was 697,657 KRW, and the incremental effectiveness based on QOL was 0.88 QALW. The incremental cost-effectiveness ratio (ICER) of the home-start group was 796,476 KRW/QALW. Based on one-way sensitivity analyses, the ICER was predicted to increase to 1,626,988 KRW/QALW if the weekly cost of home-based hospice doubled, but it was estimated to decrease to -2,898,361 KRW/QALW if death rates at home doubled. Conclusion: Home-based hospice-palliative care may be more cost-effective than inpatient hospice-palliative care. Home-based hospice appears to be affordable even if the associated medical expenditures double.

Pure Laparoscopic Living Donor Right Hepatectomy Using Real-Time Indocyanine Green Fluorescence Imaging.

INTRODUCTION: In recent decades, the quantitative and technological development of laparoscopic liver resection has resulted in an extension into the transplantation area.1,2 However, laparoscopic living donor hepatectomy is still in its infancy due to technical difficulties and extreme caution regarding donor safety.3 Several experienced major centers have demonstrated the feasibility and safety of laparoscopic living donor hepatectomy, and recent advances in laparoscopic imaging technology support this move.4 In particular, indocyanine green near-infrared fluorescence imaging helps determine the correct liver parenchyma anatomical resection and the exact point of bile duct division.4-6 This video demonstrates the technique of pure laparoscopic living donor right hepatectomy and the usefulness of indocyanine green fluorescence imaging. METHODS: The donor was a 32-year-old gentleman who decided to donate part of his liver to his wife who was suffering from viral liver cirrhosis and hepatocellular carcinoma. His BMI was 20.3 kg/m2 and the preoperatively estimated donor's right liver volume was 836 ml, representing 63.6% of his entire liver. With the recipient's weight of 57 kg, the graft-to-recipient weight ratio (GRWR) was 1.6%. The liver had classic hilar anatomy except that the right posterior intrahepatic duct was joined separately to the left main hepatic duct. The patient setting and the placement of the trocars were the same as for our conventional laparoscopic right hepatectomy technique.7 After right hepatic artery and portal vein isolation and clamping, 2.5 mg of indocyanine green was injected intravenously. RESULTS: Total operation time was 370 min and estimated blood loss was 150 ml without transfusion. Indocyanine green fluorescence imaging clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. His postoperative course was uneventful, and he was discharged on postoperative day 7. CONCLUSION: Real-time indocyanine green fluorescence imaging may be particularly helpful for delineating the anatomical surgical plane and determining the appropriate division point of the hepatic duct during laparoscopic living donor hepatectomy.