The Potential Economic Benefits of an Alarm Service in Order Communication Systems in Korea: a Cost-Effectiveness Analysis of Less-Intensive Fracture Liaison Services Based on a Prospective Cohort Study.

An alarm service in an order communication system (OCS) was found to be effective at increasing the rate of dual-energy X-ray absorptiometry (DXA) testing and treatment in South Korea, but its cost-effectiveness remains unknown. We used a Markov model to determine the cost-effectiveness of the alarm service in the OCS compared to no alarm service for the post-fracture management of subjects aged 50 years and older with fragility fractures. DXA testing and treatment data were collected from a prospective cohort study. The prevalence of osteoporotic fractures, the subsequent risk of hip fracture, and healthcare costs were obtained using Korea National Health Insurance claims data. The lifetime cost and quality-adjusted life-years (QALYs) gained were estimated from a healthcare perspective. A probabilistic sensitivity analysis was performed to examine the uncertainty of the results. The alarm service increased treatment by 125 per 1000 patients and prevented 3 hip fractures per 1000 patients. The alarm service cost an additional 249,393 KRW and resulted in an increase of 0.008 QALYs per patient compared to no alarm service. The incremental cost-effectiveness ratio was 31,174,125 KRW (26,843 USD) per QALY gained. The alarm service was cost-effective than no alarm service if the willingness to pay setting as 1GDP per capita (29,288 USD) per QALY gained. This study shows that less-intensive fracture liaison services, such as an alarm service, are cost-effective for patients aged 50 years and older with osteoporotic fractures in Korea. An intensive model, including enhanced identification and education, could further prevent the risk of refracture and improve cost-effectiveness.

Current Incidence and Future Projection of Periprosthetic Fractures in South Korea: A Study Based on National Claim Database.

OBJECTIVE: To evaluate the current incidence and economic cost and to estimate the future burden of periprosthetic fracture (PF) after joint arthroplasties in South Korea. METHODS: This study was a retrospective registry-based study of patients who were diagnosed as periprosthetic fractures (PFs) in South Korea. Cases of PF from 2010 to 2017 in South Korea using Health Insurance and Review and Assessment (HIRA) database, which contains all medical claims for all South Korean patients, were identified. The operational definitions of PFs were identified from the Electronic Data Interchange (EDI) code of the Korean National Health Insurance Program (KHNIP). The annual incidence and medical costs during the period were calculated and the future increase of PF and its cost were projected through 2030 using generalized linear model with quasi-poisson link. RESULTS: During the 8-year period, 14,456 patients were treated due to PFs. The annual number of patients with PF remarkably increased from 1,322 in 2010 to 2,636 in 2017. The increment was prominent in age groups of 70-79 and ≧80. Total number of patients with PF were 9752 in women and 4704 in men during the study period. Mean personal costs were 1,155.4 USD in women and 1,185.5 USD in men. The total cost of PFs increased from 779,533 USD in 2010 to 3,888,402 USD in 2017. The personal cost of PFs also increased from 589.7 USD in 2010 to 1,475.1 USD in 2017. In 2017, the number of PF patients exponentially increased after 50 years of age especially in women. Estimated with our projection model, the number of PFs will increase by 2.5 times and the cost will increase by 10 times in the next 10 years. CONCLUSION: The incidence and cost of PFs are rising and will represent a serious socioeconomic burden in South Korea.

Current and Future Burden of Periprosthetic Joint Infection from National Claim Database.

BACKGROUND: Periprosthetic joint infection (PJI) is the most serious complication after total joint arthroplasty. The incidence and burden of PJI in North America have been reported. There might be potential differences according to ethnics and regional practices between western countries and East Asia. Nevertheless, its incidence in East Asia remains unknown. We aimed to evaluate the incidence and economic burden of PJI in Korea and to project the future burden. METHODS: We identified numbers of total hip arthroplasties, total knee arthroplasties and PJIs in Korea from 2010 to 2018 using medical claim data of Korean Health Insurance and Review and Assessment. Annual incidence and medical cost of PJI were calculated. We projected future burden of PJI through 2030 using Quasi-poisson regression model. RESULTS: The annual incidence of PJI ranged from 2.3% to 2.8% and the average cost per each PJI patient ranged from $4,361 to $6,016. Total annual cost of PJI increased from $8.0 million in 2010 to $18.0 million in 2018 and was projected to exceed $57.0 million by 2030. CONCLUSION: The incidence of PJI in Korea is comparable with reported PJI incidence of 2.0%-2.7% in the United States. Our findings would be used for worldwide comparison of PJI epidemiology and establishment of healthcare policies for PJI in East Asia.

Assessment of patient-reported outcomes (PROs): treatment satisfaction, medication adherence, and quality of life (QoL) and the associated factors in postmenopausal osteoporosis (PMO) patients in Korea.

Patient-reported outcomes (PROs) provide practical guides for treatment; however, studies that have evaluated PROs of women in Korea with postmenopausal osteoporosis (PMO) are lacking. This cross-sectional, multi-center (29 nationwide hospitals) study, performed from March 2013 to July 2014, aimed to assess PROs related to treatment satisfaction, medication adherence, and quality of life (QoL) in Korean PMO women using osteoporosis medication for prevention/treatment. Patient demographics, clinical characteristics, treatment patterns, PROs, and experience using medication were collected. The 14-item Treatment Satisfaction Questionnaire for Medication (TSQM) (score-range, 0-100; domains: effectiveness, side effects, convenience, global satisfaction), Osteoporosis-Specific Morisky Medication Adherence Scale (OS-MMAS) (score-range, 0-8), and EuroQol-5 dimensions questionnaire (index score range, - 0.22 to 1.0; EuroQol visual analog scale score range, 0-100) were used. To investigate factors associated with PROs, linear (treatment satisfaction/QoL) or logistic (medication adherence) regression analyses were conducted. A total of 1804 patients (age, 62 years) were investigated; 60.1% used bisphosphonate, with the majority (67.2%) using weekly medication, 27.8% used daily hormone replacement therapy, and 12.1% used daily selective estrogen receptor modulator. Several patients reported gastrointestinal (GI) events (31.6%) and dental visits due to problems (24.1%) while using medication. Factors associated with the highest OS-MMAS domain scores were convenience and global satisfaction. GI events were associated with non-adherence. TSQM scores for effectiveness, side effects, and GI risk factors were significantly associated with QoL. Our study elaborately assessed the factors associated with PROs of Korean PMO women. Based on our findings, appropriate treatment-related adjustments such as frequency/choice of medications and GI risk management may improve PROs.

Effect of improved medication adherence on health care costs in osteoporosis patients.

Osteoporosis is a chronic disease that requires continuous health care spending for pharmacotherapy and examinations. Osteoporotic fractures are a major economic burden. However, little is known about the economic effects of osteoporosis and osteoporotic fractures in Korea.The purpose of this study was to determine the predictors of osteoporosis-related health care costs and to evaluate the economic effects of fracture prevention through medication adherence among osteoporosis patients.Using the Korea National Health Insurance Claims Database (KNHICD), we identified osteoporosis patients aged 50 years and older from 2011 to 2012. Annual health care costs of osteoporosis were analyzed from the insurer's perspective and compared between patients with fractures and those without fractures. Adherents were defined as patients with a medication possession ratio of ≥80%. A generalized linear model (GLM) was used to estimate the predictors of osteoporosis-related health care costs.The major predictors of osteoporosis-related health care costs were age, medication adherence, and the occurrence of fractures (P < .001). The proportion of fractures among non-adherents was approximately 1.1 times the proportion among adherents. Health care costs per patient with fractures were 3.8 times the costs per patient without fractures. Patients with fractures had higher health care costs due to hospitalization and outpatient costs but lower pharmacy costs than non-adherents. We estimated that about $5 million of health insurance expenses could be saved annually if all non-adherents became adherents.Improved osteoporosis medication adherence can reduce osteoporosis-related health care costs by preventing fractures. Persistent pharmacotherapy for osteoporosis is necessary to prevent osteoporotic fractures and to reduce osteoporosis-related health care costs.

Economic Burden of Osteoporosis in South Korea: Claim Data of the National Health Insurance Service from 2008 to 2011.

The purpose of this study was to estimate the current economic burden of osteoporosis in South Korea using national claim data of the Korean National Health Insurance Service (KNHIS) from 2008 to 2011. Patients aged 50 years or older were identified from KNHIS nationwide database for all records of outpatient visits or hospital admissions. Healthcare costs for osteoporotic patients included direct medical costs for hospitalization, outpatient care, and prescription drugs for the year after discharge. Healthcare costs were estimated based on the perspective of KNHIS, and calculated using a bottom-up approach. Between 2008 and 2011, total healthcare costs for osteoporotic patients increased from 3976 million USD to 5126 million USD, with an annual increase of 9.2% which accounted for one-sixth (16.7%) of national healthcare expenditure. Healthcare cost for hospitalization was the highest ($1903 million, 40.0% of total healthcare cost), followed by cost for outpatient care ($1474 million, 31.0%) and cost for prescription drugs ($1379 million, 29.0%). Although total healthcare cost for osteoporotic men was 6 times lower than that for osteoporotic women, the cost per person was 1.5 times higher than that for women. Total healthcare cost for osteoporotic patients without fractures was higher than that for osteoporotic patients with fractures. However, cost per person was the opposite. Osteoporosis entails substantial epidemiologic and economic burden in South Korea. This study provides information about the total healthcare burden, which could be important when determining what attention and awareness osteoporosis should be given in the public health system.

Healthcare Costs of Osteoporotic Fracture in Korea: Information from the National Health Insurance Claims Database, 2008-2011.

BACKGROUND: The present study estimated healthcare costs of osteoporotic fractures including spine, hip, distal radius and humerus in Koreans over 50 years of age using national claims data. METHODS: Korea National Health Insurance data between 2008 and 2011 was searched for all claims records of outpatient visits or hospital admissions of patients ≥50-year-of-age. Osteoporosis-related fractures were identified using certain the International Classification of Diseases, Tenth Revision codes and site-specific physician claims for procedures in a patient age cut-off value of 50 years. The healthcare costs included acute phase costs accounting for emergency medical care given immediately after fracture, costs due to further hospitalization and surgical procedures, physiotherapy sessions according to the site of the fracture, and outpatient visits in the year after discharge. RESULTS: The total estimated healthcare costs of osteoporotic fractures in 2011 was $722 million. From 2008 to 2011, the total number and healthcare costs of osteoporotic fractures increased 28.9% (from 127,070 to 163,823) and 31.6% (from $549 million to $722 million), respectively. The portion of national health care expenditure was ranged from 2.3% in 2008 to 2.2% in 2011. The mean healthcare cost of osteoporotic fractures per person increased 2.1% from $4,321 in 2008 to $4,410 in 2011.The mean healthcare costs were highest for hip fractures followed by spine, humerus, and distal radius fractures. CONCLUSIONS: Total Healthcare costs of osteoporotic fractures in South Koreans ≥50-year-of-age increased between 2008 and 2011. This trend will likely continue, which is an important health problem in the elderly population and economically.

Which Bisphosphonate? It's the Compliance!: Decision Analysis.

BACKGROUND: The best options of several bisphosphonates for prevention of osteoporotic fractures in postmenopausal women remain controversial. We determined which bisphosphonate provides better efficacy in prevention of osteoporotic fractures using a decision analysis tool, in terms of quality of life. METHODS: A decision analysis model was constructed containing final outcome score and the probability of vertebral and hip fracture within 1 year. Final outcome was defined as health-related quality of life, and was used as an utility in the decision tree. Probabilities were obtained by literature review, and health-related quality of life was evaluated by consensus committee. A roll back tool was used to determine the best bisphosphonate, and sensitivity analysis was performed to compensate for decision model uncertainty. RESULTS: The decision model favored bisphosphonate with higher compliance in terms of quality of life. In one-way sensitivity analysis, ibandronate was more beneficial than the others, when probability of compliance on ibandronate was above 0.589. CONCLUSIONS: In terms of quality of life, the decision analysis model showed that compliance was most important for patients in real world, regardless of type of bisphosphonate.

Trends of Incidence, Mortality, and Future Projection of Spinal Fractures in Korea Using Nationwide Claims Data.

Spinal fractures have been recognized as a major health concern. Our purposes were to evaluate the trends in the incidence and mortality of spinal fractures between 2008 and 2012 and predict the number of spinal fractures that will occur in Korea up to 2025, using nationwide data from the National Health Insurance Service (NHIS). A nationwide data set was evaluated to identify all new visits to medical institutes for spinal fractures in men and women aged 50 years or older between 2008 and 2012. The incidence, mortality rates and estimates of the number of spinal fractures were calculated using Poisson regression. The number of spinal fractures increased over the time span studied. Men and women experienced 14,808 and 55,164 vertebral fractures in 2008 and 22,739 and 79,903 in 2012, respectively. This reflects an increase in the incidence of spinal fractures for both genders (men, 245.3/100,000 in 2008 and 312.5/100,000 in 2012; women, 780.6/100,000 in 2008 and 953.4/100,000 in 2012). The cumulative mortality rate in the first year after spinal fractures decreased from 8.51% (5,955/69,972) in 2008 to 7.0% (7,187/102,642) in 2012. The overall standardized mortality ratio (SMR) of spinal fractures at 1 year post-fracture was higher in men (7.76, 95% CI: 7.63-7.89) than in women (4.70, 95% CI: 4.63-4.76). The total number of spinal fractures is expected to reach 157,706 in 2025. The incidence of spinal fractures increased in Korea in the last 5 years, and the socioeconomic burden of spinal fractures will continue to increase in the near future.

Osteoporotic Fracture Risk Assessment Using Bone Mineral Density in Korean: A Community-based Cohort Study.

BACKGROUND: Fracture-risk assessment tool (FRAX) using just clinical risk factors of osteoporosis has been developed to estimate individual risk of osteoporotic fractures. We developed prediction model of fracture risk using bone mineral density (BMD) as well as clinical risk factors in Korean, and assessed the validity of the final model. METHODS: To develop and validate an osteoporotic FRAX, a total of 768 Korean men and women aged 50 to 90 years were followed for 7 years in a community-based cohort study. BMD as well as clinical risk factors for osteoporotic fracture including age, sex, body mass index, history of fragility fracture, family history of fracture, smoking status, alcohol intake, use of oral glucocorticoid, rheumatoid arthritis, and other causes of secondary osteoporosis were assessed biannually. RESULTS: During the follow-up period, 86 osteoporotic fractures identified (36 in men and 50 in women). The developed prediction models showed high discriminatory power and had goodness of fit. CONCLUSIONS: The developed a Korean specific prediction model for osteoporotic fractures can be easily used as a screening tool to identify individual with high risk of osteoporotic fracture. Further studies for validation are required to confirm the clinical feasibility in general Korean population.

Risk of fractures in subjects with antihypertensive medications: A nationwide claim study.

BACKGROUND: The effect of antihypertensives on fracture has important clinical implications, since antihypertensives are frequently prescribed with lifelong exposure. This study aimed to compare risk of fracture between antihypertensive medication classes and non-users among adults. METHODS: Nationwide claim data from January 1, 2007 to December 31, 2011 were analyzed. Among 8,315,709 subjects with antihypertensive prescriptions in nationwide medical claim database in South Korea, 528,522 subjects, who initiated single-drug antihypertensives or non-users, were analyzed. Subjects were classified as non-user, alpha-blocker (AB), angiotensin-converting-enzyme-inhibitor (ACEI), angiotensin-receptor-blocker (ARB), beta-blocker (BB), calcium-channel-blocker (CCB), and diuretic users. Subjects with combination antihypertensive medications were excluded. RESULTS: A total of 16,805 fracture outcomes were observed during mean follow-up duration of 1.9 years. Fracture rate per 10,000 person-years varied significantly across type of antihypertensives, with ARB having the lowest rate (152.7, 95% confidence interval (CI) 145.4-160.4), and AB having the highest rate (323.7, 95% CI 237.4-441.4). Non-users had fracture rates (152.2, 95% CI 148.7-155.7) similar to ARB users. In models adjusting for age, gender, comorbidity score, diagnosis of diabetes, diagnosis of osteoporosis, osteoporosis treatment, and osteoporosis related diseases, AB users (adjusted hazard ratio (aHR)=2.26), ACEI users (aHR=1.68), diuretic users (aHR=1.45), CCB users (aHR=1.23), and BB users (aHR=1.15) showed significantly increased risk of fractures compared with non-users (P<0.05). Only the fracture risk of ARB users (aHR=1.00, 95% CI 0.95-1.05) was not significantly different from the non-users. CONCLUSIONS: The use of antihypertensives except for ARB is associated with increased risk of fracture, with ACEI and AB having higher risk among hypertensive adults.

Epidemiology of hip replacements in Korea from 2007 to 2011.

We analyzed national data collected by the Health Insurance Review and Assessment Service in Korea from 2007 to 2011; 1) to document procedural numbers and procedural rate of bipolar hemiarthroplasty (BH), primary and revision total hip arthroplasties (THAs), 2) to stratify the prevalence of each procedure by age, gender, and hospital type, and quantified, 3) to estimate the revision burden and evaluate whether the burden is changed over time. Our final study population included 60,230 BHs, 40,760 primary THAs, and 10,341 revision THAs. From 2007 to 2011, both the number and the rate of BHs, primary THAs increased steadily, whereas there was no significant change in revision THAs. Over the 5 yr, the rate of BHs and primary THAs per 100,000 persons significantly increased by 33.2% and 21.4%, respectively. The number of revision THAs was consistent over time. The overall annual revision burden for THA decreased from 22.1% in 2007 to 18.9% in 2011. In contrast to western data, there were no changes in the number and rate of revision THAs, and the rates of primary and revision THAs were higher for men than those for women. Although 5 yr is a short time to determine a change in the revision burden, there have been significant decreases in some age groups.

Poor prognosis in elderly patients who refused surgery because of economic burden and medical problem after hip fracture.

Although many studies have assessed mortality and morbidity of conservative treatment after hip fracture in elderly patients, the mortality of conservative treatment done because of economic burden is unclear. Among 451 patients diagnosed with displaced hip fracture during 3 yr, 28 patients (Group I) were enrolled as conservative treatment. Fifty-six patients matched in age, gender, ASA score, and diagnosis (Group II) who had undergone surgical treatment were used as the control group. The causal factors of non-operative treatment and mortality rate and functional recovery were evaluated according to the causal factors of patients with surgical procedure. Ten patients (36%) in Group I involved medical problems and 18 (64%) by economic burdens. The cumulative mortality rate over 3, 6, 12, and 24 months was 54%, 61%, 64%, and 82% in Group I and 9%, 11%, 14%, and 21% in Group II, respectively. At the latest follow-up, all five patients in Group I displayed a nonfunctional ambulatory state, whereas only seven of 44 patients in Group II were in a nonfunctional ambulatory state. Non-surgical treatment following hip fracture that is done because of the economic burden is associated with substantially high mortality and serious functional loss.

Conflict of interest in the assessment of botulinum toxin A injections in patients with cerebral palsy: a systematic review.

BACKGROUND: The efficacy of using botulinum toxin A injections in cerebral palsy (CP) is controversial. The financial conflict of interest related to medical research can affect the conclusion of an evidence-based review. This study was performed to determine as to what proportion of studies on botulinum toxin A injections in patients with CP was sponsored by the industry and whether the assessments of botulinum toxin injection in CP were associated with industry support. METHODS: Studies were identified with a search of the PubMed database (January 1991 to November 2011). All prospective, comparative, English language studies on the use of botulinum toxin A injections in patients with CP were included. A total of 374 articles were screened, 128 potentially eligible full articles were retrieved, and 66 studies met our inclusion criteria. The funding sources of the articles were reviewed, and qualitative conclusions regarding the effect of botulinum toxin A injection were classified as being either favorable, neutral, or unfavorable. RESULTS: Of 66 eligible articles, 28 were funded by the industry, and 25 were not. The other 13 studies did not include information on the funding source. A significant association was observed between the funding source and qualitative conclusions (P=0.042). Fifteen (53.6%) of the 28 industry-sponsored studies had favorable conclusions, whereas only 5 (20%) of the 25 non-industry-sponsored studies had favorable conclusions. CONCLUSIONS: About half of studies on the effect of botulinum toxin A in CP were sponsored by the industry. This systematic review revealed that the qualitative conclusions in those studies are more favorable to the use of the botulinum toxin A than the non-industry-sponsored studies. Clinicians should be aware of an industry-related conflict of interest regarding reports on the efficacy of botulinum toxin A injections in patients with CP. LEVEL OF EVIDENCE: Level II-therapeutic study.

Intramedullary nail versus extramedullary plate fixation for unstable intertrochanteric fractures: decision analysis.

BACKGROUND: The best options of internal fixation for unstable intertrochanteric femoral fractures in elderly osteoporotic patients remain controversial. We determined whether intramedullary nail or extramedullary plate provides better treatment for unstable intertrochanteric fractures using a decision analysis tool that considers quality of life. METHODS: A decision analysis model was constructed containing final outcome score and the probability of mortality within 1 year, infection, and mechanical complications. Final outcome was defined as health-related quality of life and was used as a utility in the decision tree. Probabilities were obtained by literature review, and health-related quality of life was evaluated by asking 30 orthopedic experts to complete a questionnaire. A roll back tool was used to determine the best surgical option, and sensitivity analysis was performed to compensate for decision model uncertainty. RESULTS: The decision model favored intramedullary nailing in terms of quality of life. In one-way sensitivity analysis, intramedullary nailing was more beneficial than the extramedullary plating, when probability of mechanical complication after intramedullary nailing was below 0.258. CONCLUSIONS: In terms of quality of life, the decision analysis model showed that intramedullary nailing was more beneficial for patients with an unstable intertrochanteric fracture.

National healthcare budget impact analysis of the treatment for osteoporosis and fractures in Korea.

BACKGROUND: This study was to determine the impact on the national healthcare expenditure for the treatment of osteoporosis and fractures if the coverage period for osteoporosis medication was extended from maximum a year to continuous period as required. METHODS: Preserving the current reimbursement guidelines, maximum one year's coverage for osteoporosis medication was set as scenario A. Continuous coverage for patients who require medication was set as scenario B. As costs of medical service utilization are paid by the Korean National Health Insurance Program, all items were investigated and analyzed from the payer's perspective. The combined treatment costs for osteoporosis and osteoporotic fractures were assessed for each scenario. RESULTS: Over five years the cost of osteoporosis medication in scenario A will increase from 184.3 billion KRW to 204.6 billion KRW. The cost of osteoporotic fracture treatment will increase from 1,037.3 billion KRW to 1,822.7 billion KRW. In scenario B, the cost of osteoporosis medication will increase from 209.5 billion KRW to 388.1 KRW. The cost of osteoporotic fracture treatment will increase from 600.0 billion KRW to 1,054.3 billion KRW. The result showed savings of 2.50 trillion KRW cumulatively for five years when reimbursement coverage for osteoporosis treatments is extended from one year to as long as it's clinically required. CONCLUSIONS: This study demonstrates that effective osteoporosis management through appropriate insurance coverage for osteoporosis medication should be considered not only for the patient's viewpoint, but in terms of national insurance budget as well.

Conflict of interest in the assessment of thromboprophylaxis after total joint arthroplasty: a systematic review.

BACKGROUND: The choice of modalities for thromboprophylaxis after total joint arthroplasty is controversial. To address this issue, an evidence-based review of previous studies was performed. The characteristics of the studies selected for review can affect the final conclusion of an evidence-based review. One such characteristic, financial conflict of interest related to medical research, is a widespread concern. The purpose of the present study was to determine what proportion of studies on thromboprophylaxis after total joint arthroplasty were sponsored by industry and whether the assessments of thromboprophylaxis after total joint arthroplasty were associated with industry support. METHODS: We searched PubMed for prospective, original, English-language studies, published from 2004 to 2010, on thromboprophylaxis after total joint arthroplasty. The funding sources of the articles were reviewed, and qualitative conclusions regarding the modality of interest for thromboprophylaxis after total joint arthroplasty were classified as being favorable, neutral, or unfavorable. RESULTS: Seventy-one eligible articles were identified; fifty-two were funded by industry, and fourteen were not. The other five studies did not include information about the funding source. A significant association was observed between the funding source and qualitative conclusions (p = 0.033). Only two (3.8%) of the fifty-two industry-sponsored studies had unfavorable conclusions, whereas three (21.4%) of the fourteen non-industry-sponsored studies indicated that, depending on the clinical scenario, the modality examined was neither effective nor safe. CONCLUSIONS: Most studies on thromboprophylaxis after total joint arthroplasty are sponsored by industry. Moreover, the qualitative conclusions in those studies are favorable to the use of the sponsored prophylactic agent.