Assessment of Disability and Depression Following Amputation Among Adults in Korea.

This nationwide, population-based, retrospective cohort study assesses the risk of depression following amputation among adults in Korea.

The Korea National Disability Registration System.

The Korea National Disability Registration System (KNDRS) was established in 1989 to provide social welfare benefits based on predefined criteria for disability registration and an objective medical assessment using a disability grading system. Disability registration requires (1) a medical examination by a qualified specialist physician and (2) a medical advisory meeting to review the degree of disability. Medical institutions and specialists for the diagnosis of disabilities are legally stipulated, and medical records for a specified period are required to support the diagnosis. The number of disability types has gradually expanded, and 15 disability types have been legally defined. As of 2021, 2.645 million people were registered as disabled, accounting for approximately 5.1% of the total population. Among the 15 disability types, disabilities of the extremities account for the largest proportion (45.1%). Previous studies have investigated the epidemiology of disabilities using data from the KNDRS, combined predominantly with data from the National Health Insurance Research Database (NHIRD). Korea has a mandatory public health insurance system that covers the entire Korean population, and the National Health Insurance Services manages all eligibility information, including disability types and severity ratings. In short, the KNDRS-NHIRD is a significant data resource for research on the epidemiology of disabilities.

Are high medical costs incurred by people with disabilities excessive?: An empirical analysis of Korean National Health Insurance Data.

A crude comparison of medical costs between people with disabilities (PWD) and without disabilities (PWoD) shows a much higher expenditure among PWD and such results have been a cause for further stigmatization. This study aims to empirically analyze whether the medical costs for PWD are actually high when characteristics related to medical costs are adjusted. Ten percent of the total population was randomly selected from the Korean National Health Insurance (NHI) Database in 2016. A crude comparative analysis was performed to calculate the medical cost of PWD and PWoD. A subsequent multiple regression analysis was conducted to adjust factors affecting the medical costs such as socioeconomic status, disease, and health behavior-related characteristics. The medical cost for PWD was 3.6 times higher than that for PWoD by crude comparison. However, after multiple regression analysis, margin of difference decreased to 1.5 times although the cost for PWD remained higher. Substantial decrease in higher medical costs for PWD after multiple analyses compared to crude analysis implies that additional adjustment using variables such as disease severity, not available in the NHI database, may predict a further reduction in differences. Thus, it is difficult to determine that the medical expenditure for PWD is excessive.

Factors associated with the comprehensive needs of caregivers of childhood cancer survivors in Korea.

PURPOSE: Caregivers of childhood cancer survivors (CCS) have diverse needs, which should be addressed to provide comprehensive cancer care. We aimed to evaluate the unmet needs of caregivers of CCS. METHODS: The subjects were 700 caregivers recruited at three major hospitals in South Korea. We collected study data using self-administered questionnaires and a thorough review of medical records. We assessed the unmet needs of caregivers using the comprehensive needs assessment tool for cancer caregivers and evaluated factors associated with the highest tertile range of unmet needs by multiple logistic regression analysis. RESULTS: The greatest unmet needs of caregivers had to do with healthcare staff, followed by information. Compared with father-caregivers, mother-caregivers had greater unmet needs related to health and psychological problems, family/social support, and religious/spiritual support, with odds ratios (95% confidence interval) of 3.79 (2.52-5.69), 3.17 (2.09-4.81), and 1.69 (1.14-2.50), respectively. Compared with caregivers of the youngest CCS (< 6 years), caregivers of CCS aged 12-18 years and caregivers of the oldest CCS (≥ 19 years) respectively showed 2.62 (1.24-5.52) and 3.18 (1.34-7.55) times greater unmet needs for information. Caregivers of CCS who received haematopoietic stem-cell transplantation had a 2.01-fold (1.14-3.57) greater need for practical support. CONCLUSION: Caregivers of CCS had substantial unmet needs required for comprehensive care for CCS. Several individual characteristics of caregivers and their children were significantly associated with greater unmet needs of the caregivers. IMPLICATIONS FOR CANCER SURVIVORS: Personalized support based on the characteristics of both CCS and their caregivers is required to provide comprehensive care for CCS.

Nonalcoholic fatty liver disease is associated with the development of obstructive sleep apnea.

Increasing evidence suggests that obstructive sleep apnea (OSA) is a metabolic syndrome-related disease; however, the association between nonalcoholic fatty liver disease (NAFLD) and OSA is not firmly established. In this study, we investigated the relationship between NAFLD and OSA in a general population drawn from a nationwide population-based cohort. Data from the Korean National Health Insurance System between January 2009 and December 2009 were analyzed using Cox proportional hazards model. NAFLD was defined as a fatty liver index (FLI) ≥ 60 in patients without excessive alcohol consumption (who were excluded from the study). Newly diagnosed OSA during follow-up was identified using claims data. Among the 8,116,524 participants, 22.6% had an FLI score of 30-60 and 11.5% had an FLI ≥ 60. During median follow-up of 6.3 years, 45,143 cases of incident OSA occurred. In multivariable analysis, the risk of OSA was significantly higher in the higher FLI groups (adjusted hazard ratio [aHR] 1.15, 95% confidence interval [CI] 1.12-1.18 for FLI 30-60 and aHR 1.21, 95% CI 1.17-1.26 for FLI ≥ 60). These findings were consistent regardless of body mass index and presence of abdominal obesity. In conclusion, a high FLI score may help identify individuals with a high risk of OSA. Understanding the association between NAFLD and OSA may have clinical implications for risk-stratification of individuals with NAFLD.

Disparities in the Diagnosis and Treatment of Gastric Cancer in Relation to Disabilities.

INTRODUCTION: We investigated potential disparities in the diagnosis, treatment, and survival of gastric cancer (GC) patients with and without disabilities. METHODS: We linked Korean National Disability Registry data with the Korean National Health Insurance database and Korean Central Cancer Registry data. This study included a total of 16,849 people with disabilities and 58,872 age- and sex-matched control subjects in whom GC had been diagnosed. RESULTS: When compared to GC patients without disabilities, patients with disabilities tended to be diagnosed at a later stage (localized stage 53.7% vs 59.0% or stage unknown 10.7% vs 6.9%), especially those with severe disabilities (P < 0.001). This was more evident in patients with mental impairment (localized stage 41.7% and stage unknown 15.2%). In addition, not receiving treatment was more common in patients with disabilities than those without disabilities (29.3% vs 27.2%, P < 0.001), and this disparity was more evident in those with severe disabilities (35.4%) and in those with communication (36.9%) and mental (32.3%) impairment. Patients with disabilities were at slightly higher risk of overall mortality as well as GC-specific mortality compared to people without disabilities (adjusted hazard ratio [aHR] = 1.18, 95% confidence interval: 1.14-1.21 and aHR = 1.12, 95% confidence interval: 1.09-1.16, respectively), and these disparities were more pronounced in those with severe disabilities (aHR = 1.62 and 1.51, respectively). DISCUSSION: Patients with disabilities, especially severe disabilities, were diagnosed with GC at a later stage, received less staging evaluation and treatment, and their overall survival rate was slightly worse compared to those without disabilities.

Association between perception of care coordination and health outcomes in Korean cancer survivors.

BACKGROUND: To determine relationship between cancer survivors' perception of care coordination and their health outcomes. METHODS: Study subjects were 1306 Korean adulthood cancer survivors who were enrolled in two academic hospital and completed a questionnaire consisting of questions asking two aspects of care coordination for cancer treatment they had received: 1) who played a main coordinator role and 2) whether care services had met their necessitated health concerns. We measured health outcomes including new comorbidity, number of clinic visits, health-related quality of life (HRQoL) and fear of cancer recurrence (FCR). Associations between the level of care coordination and health outcomes were evaluated by multiple logistic regression analysis after adjusting for covariates. RESULTS: Survivors with uncoordinated care were more likely to have more new comorbidities after cancer diagnosis, visit clinic more frequently and have worse HRQoL and higher FCR. Females and unmarried survivors were more likely to have received uncoordinated care than males and ever married survivors. Uncoordinated care group had an increased the risk of new comorbidity (odds ratio 1.73, [95% confidence interval] 1.02-2.92), multiple clinic visits (1.69, 1.00-2.88), severe FCR (2.28, 1.33-3.93), low EuroQoL Visual Analogue Scale (1.82, 1.28-2.60), low global health status (1.51, 1.04-2.21), and poor physical (2.00, 1.31-3.04), role (2.46, 1.69-3.56) and emotional function (2.62, 1.81-3.78). CONCLUSIONS: Coordinated care of Korean cancer survivors was associated with their health outcomes, including new comorbidity, clinic visits, HRQoL and FCR. Good care coordination may be reinforced to improve outcomes of survivorship care.

The Effect of Disability on the Diagnosis and Treatment of Multiple Myeloma in Korea: A National Cohort Study.

PURPOSE: This study aimed to determine whether the diagnosis, treatment approach, and prognosis of multiple myeloma (MM) vary according to the presence and type of disability. Materials and Methods: Demographic, socioeconomic, and medical data were obtained from the National Disability Database, the Korean Central Cancer Registry, and the Korean National Health Insurance claims database. An age- and sex-matched cohort was established using a 1:3 ratio constituted with 2,776,450 people with disabilities and 8,329,350 people without disabilities. Adult patients diagnosed with MM were subsequently selected from this cohort. Disabilities were categorized as physical, communication, intellectual or psychological, and affecting the major internal organs. RESULTS: The cohort included 4,090 patients with MM, with a significantly lower rate per 100,000 persons among people with disabilities than among people without disabilities (29.1 vs. 39.4, p < 0.001). People with disabilities were more likely to undergo dialysis treatment at the time of diagnosis (16.3% vs. 10.0%, p < 0.001), but were less likely to undergo autologous stem cell transplantation (37.5% vs. 43.7%, p=0.072). This trend was more evident among patients with intellectual or psychological disabilities. The median overall survival among patients with disabilities was significantly shorter than that among patients without disabilities (36.8 months vs. 51.2 months, p < 0.001). CONCLUSION: In Korea, people with disabilities generally have a lower rate of MM diagnosis, receive less intensive treatment, and have a lower survival rate than people without disabilities.

Impact of Continuous Care on Health Outcomes and Cost for Type 2 Diabetes Mellitus: Analysis Using National Health Insurance Cohort Database.

BACKGROUND: The objective of the study was to determine the impact of continuous care on health outcomes and cost of type 2 diabetes mellitus (T2DM) in Korea. METHODS: A nationwide retrospective, observational case-control study was conducted. Continuity of treatment was measured using Continuity of Care (COC) score. Information of all patients newly diagnosed with T2DM in 2004 was retrieved from the National Health Insurance database for the period of 2002 to 2013. The study examined 2,373 patients after applying exclusion criteria, such as for patients who died from conditions not related to T2DM. Statistical analyses were performed using frequency distribution, simple analysis (t-test and chi-squared test), and multi-method analysis (simple linear regression, logistic regression, and survival analysis). RESULTS: The overall COC score was 0.8±0.24. The average incidence of diabetic complications was 0.39 per patient with a higher COC score, whereas it was 0.49 per patient with a lower COC score. In both survival and logistic analyses, patients who had high COC score were significantly less likely to have diabetic complications (hazard ratio, 0.69; 95% confidence interval, 0.54 to 0.88). The average medical cost was approximately 3,496 United States dollar (USD) per patient for patients with a higher COC score, whereas it was 3,973 USD per patient for patients with a lower COC score during the 2006 to 2013 period, with a difference of around 477 USD, which is statistically significant after adjusting for other factors (ß=-0.152). CONCLUSION: Continuity of care for diabetes significantly reduced health complications and medical costs from patients with T2DM.

Cancer cost communication: experiences and preferences of patients, caregivers, and oncologists-a nationwide triad study.

PURPOSE: We assessed cost communication between cancer patients, caregivers, and oncologists and identified factors associated with communication concordance. METHODS: A national, multicenter, cross-sectional survey of patient-caregiver-oncologist triads was performed, and 725 patient-caregiver pairs, recruited by 134 oncologists in 13 cancer centers, were studied. Discordance in preferences and experiences regarding cost communication between patients, caregivers, and oncologists were assessed. Hierarchical generalized linear models were used to identify predictors of concordance and to identity the possible association of concordance with patient satisfaction and degree of trust in the physician. RESULTS: Although the oncologists thought that patients would be affected by the cost of care, only half of them were aware of the subjective burden experienced by their patients, and the degree of concordance for this parameter was very low (weighted kappa coefficient = 0.06). Caregivers consistently showed similar preferences to those of the patients. After controlling for covariates, the education level of patients [adjusted odds ratio (aOR) for > 12 vs. < 9 years, 2.92; 95% confidence interval (CI), 1.87-4.56], actual out-of-pocket costs [aOR for ≥ 8 million vs. < 2 million Korean Won, 0.56; 95% CI, 0.34-0.89], and physician age (aOR for ≥ 55 vs. < 45 years, 1.83; 95% CI, 1.04-3.21) were significant. CONCLUSIONS: The results show underestimation by oncologists regarding the subjective financial burden on a patient, and poor patient-physician concordance in cost communication. Oncologists should be more cognizant of patient OOP costs that are not indexed by objective criteria, but instead involve individual patient perceptions.

Disparity in Health Screening and Health Utilization according to Economic Status.

BACKGROUND: Cardiovascular disease (CVD) has become the most common cause of mortality and morbidity worldwide. Health screening is associated with higher outpatient visits for detection and treatment of CVD-related diseases (diabetes mellitus, hypertension, and dyslipidemia). We examined the association between health screening, health utilization, and economic status. METHODS: A sampled cohort database from the National Health Insurance Corporation was used. We included 306,206 participants, aged over 40 years, without CVD (myocardial infarction, stroke, and cerebral hemorrhage), CVD-related disease, cancer, and chronic renal disease. The follow-up period was from January 1, 2003 through December 31, 2005. RESULTS: Totally, 104,584 participants received at least one health screening in 2003-2004. The odds ratio of the health screening attendance rate for the five economic status categories was 1.27 (95% confidence interval [CI], 1.24 to 1.31), 1.05 (95% CI, 1.02 to 1.08), 1, 1.16 (95% CI, 1.13 to 1.19) and 1.50 (95% CI, 1.46 to 1.53), respectively. For economic status 1, 3, and 5, respectively, the diagnostic rate after health screening was as follows: diabetes mellitus: 5.94%, 5.36%, and 3.77%; hypertension: 32.75%, 30.16%, and 25.23%; and dyslipidemia: 13.43%, 12.69%, and 12.20%. The outpatient visit rate for attendees diagnosed with CVD-related disease was as follows for economic status 1, 3, and 5, respectively: diabetes mellitus: 37.69%, 37.30%, and 43.70%; hypertension: 34.44%, 30.09%, and 32.31%; and dyslipidemia: 18.83%, 20.35%, and 23.48%. CONCLUSION: Thus, higher or lower economic status groups had a higher health screening attendance rate than the middle economic status group. The lower economic status group showed lower outpatient visits after screening, although it had a higher rate of CVD diagnosis.

Enhancing physical activity and reducing obesity through smartcare and financial incentives: A pilot randomized trial.

OBJECTIVE: A pilot randomized trial assessed the feasibility and effectiveness of an intervention combining Smartcare (activity tracker with a smartphone application) and financial incentives. METHODS: A three-arm, open-label randomized controlled trial design involving traditional education, Smartcare, and Smartcare with financial incentives was involved in this study. The latter group received financial incentives depending on the achievement of daily physical activity goals (process incentive) and weight loss targets (outcome incentive). Male university students (N = 105) with body mass index of ≥27 were enrolled. RESULTS: The average weight loss in the traditional education, Smartcare, and Smartcare with financial incentives groups was -0.4, -1.1, and -3.1 kg, respectively, with significantly greater weight loss in the third group (both Ps < 0.01). The final weight loss goal was achieved by 0, 2, and 10 participants in the traditional education, Smartcare, and Smartcare with financial incentives groups (odds ratio for the Smartcare with financial incentive vs. Smartcare = 7.27, 95% confidence interval: 1.45-36.47). Levels of physical activity were significantly higher in this group. CONCLUSIONS: The addition of financial incentives to Smartcare was effective in increasing physical activity and reducing obesity.

Network analysis of human diseases using Korean nationwide claims data.

OBJECTIVE: To investigate disease-disease associations by conducting a network analysis using Korean nationwide claims data. METHODS: We used the claims data from the Health Insurance Review and Assessment Service-National Patient Sample for the year 2011. Among the 2049 disease codes in the claims data, 1154 specific disease codes were used and combined into 795 representative disease codes. We analyzed for 381 representative codes, which had a prevalence of >0.1%. For disease code pairs of a combination of 381 representative disease codes, P values were calculated by using the χ(2) test and the degrees of associations were expressed as odds ratios (ORs). RESULTS: For 5515 (7.62%) statistically significant disease-disease associations with a large effect size (OR>5), we constructed a human disease network consisting of 369 nodes and 5515 edges. The human disease network shows the distribution of diseases in the disease network and the relationships between diseases or disease groups, demonstrating that diseases are associated with each other, forming a complex disease network. We reviewed 5515 disease-disease associations and classified them according to underlying mechanisms. Several disease-disease associations were identified, but the evidence of these associations is not sufficient and the mechanisms underlying these associations have not been clarified yet. Further research studies are needed to investigate these associations and their underlying mechanisms. CONCLUSION: Human disease network analysis using claims data enriches the understanding of human diseases and provides new insights into disease-disease associations that can be useful in future research.

Attitudes towards second opinion services in cancer care: a nationwide survey of oncologists in Korea.

OBJECTIVE: Second opinion is a common phenomenon in many health systems, especially in the care of patients with cancer. However, it is not clear whether second opinion seeking should be promoted or discouraged and how second opinion services and policies can be better formalized to maximize the benefits and minimize the disadvantages. METHODS: A nationwide survey was conducted with a representative sample of 678 physicians involved in cancer care (75.5% participation rate) recruited in 13 cancer centres. RESULTS: Most physicians involved with cancer care perceived patients' second opinion seeking as a legitimate right (96.0%) and they acknowledged the need for second opinion services under certain conditions (98.2%). Many believed that second opinions can enhance patient satisfaction (77.3%) and quality of care (74.3%), but they also had concerns about increase in healthcare and societal costs (91.3%) and concentration in a high-volume centre (90.7%). While the majority agreed with the involvement of the first opinion physicians in the second opinion services (69.5%), there were mixed opinions regarding the desirability of remote (teleconsultation) second opinion services (49.0%) and coverage by national health insurance (51.9%). CONCLUSION: Physicians were generally positive to second opinion services and expected positive consequences in terms of patient satisfaction and quality of care. However, they had concerns about the consequences regarding cost and equity, and disagreements were observed regarding the way to improve second opinion services. The physicians' opinions revealed in our study will be helpful in developing clearer guidelines used to maximize the benefits of second opinion services.

Design and baseline characteristics of participants in the Enhancing Physical Activity and Reducing Obesity through Smartcare and Financial Incentives (EPAROSFI): A pilot randomized controlled trial.

BACKGROUND: An activity tracker combined with a smartphone application (smartcare) may help people track and receive feedback on their own activities. However, activity trackers themselves generally fail to drive long-term sustained engagement for a majority of users. One potential strategy for increasing the effectiveness of smartcare is through the use of incentives. The purpose of this pilot randomized trial is to test the feasibility of our intervention and to assess the extent to which smartcare with or without financial incentives can increase physical activity levels and reduce weight over a 12-week period. METHODS/DESIGN: This study employs a three-arm, open-label randomized controlled trial design: control (standard basic education), smartcare, and smartcare plus financial incentives. Male university students with body mass index ≥ 27 are enrolled. Our primary and secondary endpoints are the amount of weight loss and the level of physical activity respectively. The weight loss goal is 3% of baseline at week 4, 5% at week 8, and 7% at week 12. The daily physical activity goal was individualized according to the participants' weight. Process incentives are accumulated when participants met daily physical activity goals, and outcome incentives are provided when they met weight reduction goals. DISCUSSION: Given the global increase in physical inactivity and obesity, there is a growing need for effective, scalable, and affordable health promotion strategies. Our proof-of-concept study will provide the evidence for the combination of rising health promotion technology of activity trackers and smartphone applications with the modern concept of behavioral economics using financial incentives.

Changing Patterns of Primary Treatment in Korean Men with Prostate Cancer Over 10 Years: A Nationwide Population Based Study.

PURPOSE: We investigated changing patterns of primary treatment in Korean men with prostate cancer (PC) and impact of sociodemographic factors on treatment choice from a nationwide cohort over 10 years. MATERIALS AND METHODS: We conducted a cohort study of a 2% nationwide random sample of Korean National Health Insurance. A total of 1,382 patients who had undergone active treatments for newly diagnosed PC between 2003 and 2013 were included. Time trends in primary treatment of PC, including radical surgery, radiation therapy (RT), and androgen deprivation therapy (ADT) were analyzed. RESULTS: Total number of patients undergoing active treatments increased significantly (162%). Surgery cases showed the most significant increase, from 22.4% in 2003 to 45.4% in 2013, while the relative proportion of ADT showed a tendency to decrease from 60.3% in 2003 to 45.4% in 2013, and the relative proportion of RT was variable over 10 years (from 7.2% to 18.4%). While treatment patterns differed significantly according to age (p < 0.001) and income classes (p=0.014), there were differences in primary treatment according to residential area. In multinomial logistic regression analysis, older patients showed significant association with ADT or RT compared to surgery, while patients with higher income showed significant association with surgery. CONCLUSION: Treatment pattern in Korean PC patients has changed remarkably over the last 10 years. Sociodemographic factors do affect the primary treatment choice. Our results will be valuable in overviewing changing patterns of primary treatment in Korean PC patients and planning future health policy for PC.

Medical Costs and Healthcare Utilization among Cancer Decedents in the Last Year of Life in 2009.

PURPOSE: The purpose of this study was to evaluate the cancer care cost during the last year of life of patients in Korea. MATERIALS AND METHODS: We studied the breakdown of spending on the components of cancer care. Cancer decedents in 2009 were identified from the Korean Central Cancer Registry and linked with the Korean National Health Insurance Claims Database. The final number of patients included in the study was 70,558. RESULTS: In 2009, the average cancer care cost during the last year of life was US $15,720. Patients under age 20 spent US $53,890 while those 70 or over spent US $11,801. Those with leukemia incurred the highest costs (US $43,219) while bladder cancer patients spent the least (US $13,155). General costs, drugs other than analgesics, and test fees were relatively high (29.7%, 23.8%, and 20.7% of total medical costs, respectively). Analgesic drugs, rehabilitation, and psychotherapy were still relatively low (4.3%, 0.7%, and 0.1%, respectively). Among the results of multiple regression analysis, few were notable. Age was found to be negatively related to cancer care costs while income level was positively associated. Those classified under distant Surveillance, Epidemiology, and End Results stages of cancer and higher comorbidity level also incurred higher cancer care costs. CONCLUSION: Average cancer care costs varied significantly by patient characteristics. However, the study results suggest an underutilization of support services likely due to lack of alternative accommodations for terminal cancer patients. Further examination of utilization patterns of healthcare resources will help provide tailored evidence for policymakers in efforts to reduce the burdens of cancer care.

Treatment Gap in the National Health-screening Program in Korea: Claim-based Follow-up of Statin Use for Sustained Hypercholesterolemia.

Participation in a screening program by itself may not improve clinical outcomes. Treatment gaps in the program may limit its full benefit. We evaluated statin prescription rates for subjects with sustained hypercholesterolemia to assess the treatment gaps in the National Health Screening Program (NHSP) in Korea. A retrospective, random cohort was established among National Health Insurance Corporation (NHIC) members. Finally, we examined 465,499 individuals who attended the NHSP from 2003 to 2010 without any history of dyslipidemia, statin prescription, or hospitalization for cardiovascular events until the end of 2002. The subsequent statin prescription rates were identified from the NHIC medical service claim database from 2003 to 2011. Descriptive data and odds ratio from multivariate logistic analyses on statin prescription rates and the corresponding correlations were evaluated. The NHSP detected 114,085 (24.5%) cases of newly diagnosed hypercholesterolemia. However, only 8.6% of these received statin prescription within 6 months of diagnosis. For cases of sustained hypercholesterolemia determined in the next screening visit by the NHSP, the statin prescription rate increased, but only to 12.2%. Statin prescriptions were more common among females, older individuals, and hypertension or diabetes patients. Furthermore, the statin prescription rates had increased over the study period. The NHSP exhibited low statin prescription rate which has been improving. For the NHSP to be effective, it would be worthwhile to decrease the gap between the diagnosis of hypercholesterolemia and the following treatment.

Caregiver burden, patients' self-perceived burden, and preference for palliative care among cancer patients and caregivers.

OBJECTIVE: Recently, caregiver burden (CB) has emerged as an important issue in the area of palliative medicine. However, patients' feelings related to being a burden to their families (i.e., self-perceived burden [SPB]) is also a significant issue. We evaluated the relation of CB and SPB as preference for palliative care. METHODS: A national, multicenter, cross-sectional survey of 326 patient-caregiver dyads was performed. A set of paired questionnaires evaluating CB and SPB (five domain items assessed on a four-point Likert scale) were independently administered to patients and their caregivers. Among the respondents, only the patients with distant stage cancer and their caregivers were included. Multivariate analyses were conducted to identify the associations between CB and SPB and preference for palliative care. RESULTS: Caregivers and patients who preferred palliative care to life sustaining treatment reported higher CB and SPB scores, respectively. Caregivers who felt more of a burden were more likely to prefer palliative care over life sustaining treatment for their patients (adjusted odds ratio [aOR] = 1.67, 95% CI: 1.21-2.31). In addition, patients who perceived their caregivers' burden as large tended to prefer palliative care (aOR = 1.61, 95% CI: 1.16-2.22). CONCLUSIONS: Both CB and SPB increased preference for palliative care. This could be interpreted that high CB can lead to preference for palliative care in both patients and their caregivers, potentially threatening patient autonomy. Efforts to relieve CB and SPB are needed.

A critical assessment of the effects of tamsulosin and solifenacin as monotherapies and as a combination therapy for the treatment of ureteral stent-related symptoms: a 2 × 2 factorial randomized trial.

OBJECTIVE: To assess the efficacy of tamsulosin, solifenacin, and combination therapy of both agents for the treatment of ureteral stent-related symptoms (SRSs). METHODS: An open-label, randomized controlled trial was conducted with 112 patients who underwent unilateral ureteral stent insertion following ureteroscopic stone surgery. Patients were randomized with a 2 × 2 factorial design to one of four groups, i.e., A (control), B (tamsulosin 0.2 mg once daily), C (solifenacin 5 mg once daily), and D (both active treatments). Patients were evaluated at week 2 by the ureteral stent symptom questionnaire (USSQ). The primary efficacy outcome was the urinary symptom score of the USSQ, and the secondary efficacy outcomes were the scores in the other five USSQ domains, the Euro-QOL score, and oral analgesic requirements during the 2 weeks. Efficacy outcomes were primarily analyzed for the per-protocol set population. RESULTS: The four groups were generally well balanced in terms of baseline characteristics. Eighty-one patients (72.3 %) completed the study protocol. Comparison of the six USSQ domain scores at week 2 showed no differences between the four groups. Similarly, comparison of the domain scores stratified by tamsulosin or solifenacin medication showed no differences for either medication. The other secondary outcomes were also similar in the group comparisons. CONCLUSIONS: Neither tamsulosin nor solifenacin medications provide beneficial effects for relieving various SRSs. In addition, the combination therapy did not have beneficial effects. Further studies are warranted to determine the benefit of medical therapy for the treatment of SRSs and to determine the optimal management strategy for SRSs.