Intratumoral Budding in Pretreatment Biopsies, among Tumor Microenvironmental Components, Can Predict Prognosis and Neoadjuvant Therapy Response in Colorectal Adenocarcinoma.

Background and Objectives: The prediction of the prognosis and effect of neoadjuvant therapy is vital for patients with advanced or unresectable colorectal carcinoma (CRC). Materials and Methods: We investigated several tumor microenvironment factors, such as intratumoral budding (ITB), desmoplastic reaction (DR), and Klintrup-Mäkinen (KM) inflammation grade, and the tumor-stroma ratio (TSR) in pretreatment biopsy samples (PBSs) collected from patients with advanced or unresectable CRC. A total of 85 patients with 74 rectal carcinomas and 11 colon cancers treated at our hospital were enrolled; 66 patients had curative surgery and 19 patients received palliative treatment. Results: High-grade ITB was associated with recurrence (p = 0.002), death (p = 0.034), and cancer-specific death (p = 0.034). Immature DR was associated with a higher grade of clinical tumor-node-metastasis stage (cTNM) (p = 0.045), cN category (p = 0.045), and cM category (p = 0.046). The KM grade and TSR were not related to any clinicopathological factors. High-grade ITB had a significant relationship with tumor regression in patients who received curative surgery (p = 0.049). Conclusions: High-grade ITB in PBSs is a potential unfavorable prognostic factor for patients with advanced CRC. Immature DR, TSR, and KM grade could not predict prognosis or therapy response in PBSs.

Estimation of Excess All-cause Mortality during COVID-19 Pandemic in Korea.

BACKGROUND: Excess all-cause mortality is helpful to assess the full extent of the health impact, including direct and indirect deaths of coronavirus disease 2019 (COVID-19). The study aimed to estimate overall and regional excess all-cause mortality during the pandemic in Korea. METHODS: We obtained all-cause death data and population statistics from January 2010 to December 2020. The expected mortality in 2020 was estimated using a quasi-Poisson regression model. The model included death year, seasonal variation, cold wave (January), average death counts in the previous month, and population. Excess mortality was defined as the difference between the observed mortality and the expected mortality. Regions were classified into three areas according to the numbers of COVID-19 cases. RESULTS: There was no annual excess all-cause mortality in 2020 at the national and regional level compared to the average death for the previous ten years. The observed mortality in 2020 was 582.9 per 100,000 people, and the expected mortality was 582.3 per 100,000 people (95% confidence interval, 568.3-596.7). However, we found monthly and regional variations depending on the waves of the COVID-19 pandemic in Korea. While the mortality in August, October, and November exceeded the expected range, the mortality in September was lower than the expected range. The months in which excess deaths were identified differed by region. CONCLUSION: Our results show that the mortality in 2020 was similar to the historical trend. However, in the era of the COVID-19 pandemic, it would be necessary to regularly investigate COVID-19-related mortality and determine its direct and indirect causes.

Social Distancing and Transmission-reducing Practices during the 2019 Coronavirus Disease and 2015 Middle East Respiratory Syndrome Coronavirus Outbreaks in Korea.

BACKGROUND: The absence of effective antiviral medications and vaccines increased the focus on non-pharmaceutical preventive behaviors for mitigating against the coronavirus disease 2019 (COVID-19) pandemic. To examine the current status of non-pharmaceutical preventive behaviors practiced during the COVID-19 outbreak and factors affecting behavioral activities, we compared to the 2015 Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in Korea. METHODS: This was a serial cross-sectional population-based study in Korea with four surveys conducted on June 2 and 25, 2015 (MERS-CoV surveys), and February 4, and April 2, 2020 (COVID-19 surveys). Of 25,711 participants selected using random digit dialing numbers, 4,011 participants (aged ≥ 18 years) were successfully interviewed, for the 2020 COVID-19 (n = 2,002) and 2015 MERS-CoV (n = 2,009) epidemics were included. Participants were selected post-stratification by sex, age, and province. The total number of weighted cases in this survey equaled the total number of unweighted cases at the national level. We measured the levels of preventive behaviors (social distancing [avoiding physical contact with others]), and practicing transmission-reducing behaviors such as wearing face mask and handwashing. RESULTS: Between the surveys, respondents who reported practicing social distancing increased from 41.9%-58.2% (MERS-CoV) to 83.4%-92.3% (COVID-19). The response rate for the four surveys ranged between 13.7% and 17.7%. Practicing transmission-reducing behaviors (wearing face masks and handwashing) at least once during COVID-19 (78.8%, 80.2%) also increased compared to that during MERS-CoV (15.5%, 60.3%). The higher affective risk perception groups were more likely to practice transmission-reducing measures (adjusted odds ratio, 3.24-4.81; 95 confidence interval, 1.76-6.96) during both COVID-19 and MERS-CoV. CONCLUSION: The study findings suggest markedly increased proportions of non-pharmaceutical behavioral practices evenly across all subgroups during the two different novel virus outbreaks in Korea. Strategic interventions are needed to attempt based on preventive behavior works.

Chasms in Achievement of Recommended Diabetes Care among Geographic Regions in Korea.

BACKGROUND: Although effective care for type 2 diabetes (T2DM) is well known, considerable inadequate care has been still existed. Variations in achievement of the recommended quality indicators inT2DM care among small areas are not well known in Korea. This study examined the quality of care T2DM care and its geographical variations. METHODS: We used the national health insurance database and national health screening database. Seven quality indicators were used to evaluate continuity of care (medication possession ratio), process of care (hemoglobin A1c test, lipid profile, microalbuminuria test, and eye examination), and intermediate outcome (blood pressure control, and low-density lipoprotein control). Crude and age-standardized proportions were calculated for each 252 districts in Korea. RESULTS: All quality indicators failed to achieve the recommended level. Only about 3% and 15% of the patients underwent eye examination and microalbuminuria test, respectively. Other indicators ranged from 48% to 68%. Wide variation in the quality existed among districts and indicators. Eye examination and microalbuminuria test varied the most showing tenfold (0.9%-9.2%) and fourfold (6.3%-28.9%) variation by districts, respectively. There were 32.4 and 42.7 percentage point gap between the best and the worst districts in hemoglobin A1c test and blood pressure control, respectively. CONCLUSION: Considerable proportion of T2DM patients were not adequately managed and quality of care varied substantially district to district. To improve the quality of diabetes care, it is necessary to identify the poor performance areas and establish a well-coordinated care system tailored to the need of the district.

Effect of the Presence of Emergency Departments With 300 or More Hospital Beds in Health Service Areas on 30-Day Mortality in Korea: A Nationwide Retrospective Cross-sectional Study.

BACKGROUND: Disparities in emergency care accessibility exist between health service areas (HSAs). There is limited evidence on whether the presence of an emergency department (ED) that exceeds a certain hospital bed capacity is associated with emergency patient outcomes at the regional level. The objective of this study was to evaluate the effect of HSAs with or without of regional or local emergency centers with 300 or more hospital beds (EC300 or nEC300, respectively) by comparing the 30-day mortality of patients with severe emergency diseases (SEDs) admitted to the hospital through the ED. METHODS: The study retrospectively evaluated data from the National Health Information Database (NHID) of the National Health Insurance Service (NHIS) Claims database and enrolled patients who were admitted from the ED for SEDs. SEDs were defined using ICD-10 (International Classification of Diseases 10th Revision) codes for 28 disease categories with high severity, and 56 HSAs were designated as published by the NHIS. We performed hierarchical logistic regression analysis using multilevel models with the generalized linear mixed model (GLIMMIX) procedure to evaluate whether EC300 was associated with the 30-day mortality of SED patients, adjusting for patient-level, prehospital-level, hospital-level, and HSA-level variables. RESULTS: In total, 662 478 patients were analyzed, of whom 54 839 (8.3%) died within 30 days after hospital discharge. Of the 56 HSAs, 46 (82.1%) were included in the EC300 group. After adjustment for patient-level, prehospital-level, hospital-level, and HSA-level variables, nEC300 was significantly associated with increased 30-day mortality in SED patients (adjusted odds ratio [AOR]: 1.33, 95% CI: 1.137-1.153). In addition, patients who visited EDs with fewer annual SED admissions were associated with higher 30-day mortality. CONCLUSION: nEC300 had a greater risk of 30-day mortality in patients treated with SEDs than EC300. The results indicate that not only the number of EDs in each HSA is important for ensuring adequate patient outcomes but also the presence of EDs with adequate receiving capacity.

Association Between Risk Perceptions of COVID-19, Political Ideology, and Mask-Wearing Behavior After the Outbreak: A Cross-Sectional Survey in South Korea.

Purpose: After the declaration by the World Health Organization signaling the conclusion of the COVID-19 pandemic, most countries lifted mandatory mask-wearing regulations. This study aimed to investigate factors such as risk perception and political ideology associated with continued adherence to mask-wearing among specific populations, particularly when it is no longer deemed necessary. Methods: We conducted a cross-sectional study including a sample of 1001 respondents stratified by sex, age (≥ 18 years), and region from January 31 to February 2, 2023, after the mandatory mask regulation was lifted in South Korea. Multivariate logistic regression models were applied to estimate the relationships between risk perceptions, political ideology, and mask-wearing maintenance, adjusting for factors such as sex, age, occupation, and trust in the government. Results: Our results indicated significant associations between age, self-reported household economic status, political ideology, affective risk perception, and perceived effectiveness of the government's COVID-related measures with indoor mask-wearing. Specifically, liberals were more likely to keep mask-wearing indoors than conservatives (adjusted odds ratio [aOR]: 2.19; 95% confidence interval [CI]: 1.33-3.59); and those who perceived a greater affective risk of COVID-19 (aOR: 2.47; 95% CI: 1.96-3.10), along with those who perceived the government's countermeasures as inadequate, were more inclined to maintain the habit of wearing masks indoors (aOR: 1.90; 95% CI: 1.19-3.03). Conclusion: Our study highlighted the multifaceted factors influencing mask-wearing behavior in the post-COVID-19 era. Even after adjusting for various confounding factors, such as age, sex, and trust in the government, an association remained between affective risk perception, political ideology, and mask-wearing behavior. However, further research for psychological mechanisms is needed to foster a culture of preventive behaviors proportional to the risk of infection.

Weekend effect on 30-day mortality for ischemic and hemorrhagic stroke analyzed using severity index and staffing level.

BACKGROUND AND PURPOSE: Previous studies on the weekend effect-a phenomenon where stroke outcomes differ depending on whether the stroke occurred on a weekend-mostly targeted ischemic stroke and showed inconsistent results. Thus, we investigated the weekend effect on 30-day mortality in patients with ischemic or hemorrhagic stroke considering the confounding effect of stroke severity and staffing level. METHODS: We retrospectively analyzed data of patients hospitalized for ischemic or hemorrhagic stroke between January 1, 2015, and December 31, 2018, which were extracted from the claims database of the National Health Insurance System and the Medical Resource Report by the Health Insurance Review & Assessment Service. The primary outcome measure was 30-day all-cause mortality. RESULTS: In total, 278,632 patients were included, among whom 84,240 and 194,392 had a hemorrhagic and ischemic stroke, respectively, with 25.8% and 25.1% of patients, respectively, being hospitalized during the weekend. Patients admitted on weekends had significantly higher 30-day mortality rates (hemorrhagic stroke 16.84%>15.55%, p<0.0001; ischemic stroke 5.06%>4.92%, p<0.0001). However, in the multi-level logistic regression analysis adjusted for case-mix, pre-hospital, and hospital level factors, the weekend effect remained consistent in patients with hemorrhagic stroke (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.00-1.10), while the association was no longer evident in patients with ischemic stroke (OR 1.01, 95% CI 0.96-1.06). CONCLUSIONS: Weekend admission for hemorrhagic stroke was significantly associated with a higher mortality rate after adjusting for confounding factors. Further studies are required to understand factors contributing to mortality during weekend admission.

Changes in the Hospital Standardized Mortality Ratio Before and During the COVID-19 Pandemic: A Disaggregated Analysis by Region and Hospital Type in Korea.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has led to a global shortage of medical resources; therefore, we investigated whether COVID-19 impacted the quality of non-COVID-19 hospital care in Korea by comparing hospital standardized mortality rates (HSMRs) before and during the pandemic. METHODS: This retrospective cohort study analyzed Korean National Health Insurance discharge claim data obtained from January to June in 2017, 2018, 2019, and 2020. Patients' in-hospital deaths were classified according to the most responsible diagnosis categories. The HSMR is calculated as the ratio of expected deaths to actual deaths. The time trend in the overall HSMR was analyzed by region and hospital type. RESULTS: The final analysis included 2 252 824 patients. In 2020, the HSMR increased nationwide (HSMR, 99.3; 95% confidence interval [CI], 97.7 to 101.0) in comparison to 2019 (HSMR, 97.3; 95% CI, 95.8 to 98.8). In the COVID-19 pandemic zone, the HSMR increased significantly in 2020 (HSMR, 112.7; 95% CI, 107.0 to 118.7) compared to 2019 (HSMR, 101.7; 95% CI, 96.9 to 106.6). The HSMR in all general hospitals increased significantly in 2020 (HSMR, 106.4; 95% CI, 104.3 to 108.5) compared to 2019 (HSMR, 100.3; 95% CI, 98.4 to 102.2). Hospitals participating in the COVID-19 response had a lower HSMR (HSMR, 95.6; 95% CI, 93.9 to 97.4) than hospitals not participating in the COVID-19 response (HSMR, 124.3; 95% CI, 119.3 to 129.4). CONCLUSIONS: This study suggests that the COVID-19 pandemic may have negatively impacted the quality of care in hospitals, especially general hospitals with relatively few beds. In light of the COVID-19 pandemic, it is necessary to prevent excessive workloads in hospitals and to properly employ and coordinate the workforce.

Lessons from health insurance responses in counteracting COVID-19: a qualitative comparative analysis of South Korea and three influential countries.

BACKGROUND: The COVID-19 pandemic has caused delays and restrictions in providing medical services. In response to the medical surge, countries with social insurance systems provided financial incentives to medical institutions. This study aimed to present the directions for health insurance support by comparing countries in terms of the domains and contents of COVID-19 health insurance support to ensure timely support in case of future pandemics. METHODS: An analysis framework was developed to compare health insurance policy interventions for COVID-19 and non-COVID-19 domains, and detailed policy interventions were divided into sub-domains (space, staff, and stuff) for each domain. Data were collected by country from the websites of the Ministry of Health and Social Insurers, Organisation for Economic Co-operation and Development, and European Observatory on Health Systems and Policies and were analyzed using qualitative comparative analysis. RESULTS: The countries provided comprehensive support for both the COVID-19 and non-COVID-19 domains. In the COVID-19 domain, overall support was provided in all three sub-domains. Additional cost support was provided to prevent infection and provide secure facilities to treat confirmed patients. Outpatient services were mainly supported, and an intensive intervention was developed in the staff sub-domain for the non-COVID-19 domain. The point of policy intervention was the surge of the first confirmed case. Continuous revisions were subsequently made. The government provided financial support through health insurance. CONCLUSIONS: Regarding where policy support through health insurance should be focused, the workload of medical personnel increased according to the change in the service provision environment due to the pandemic, and the medical service delivery system changed to prevent further infection. Consequently, incentives should be provided to aid the provision of stable services to patients and should be an auxiliary means to implement the national quarantine policy more effectively via a health insurance response system that promptly provides additional financial support in case of future crises.

The association between the risk perceptions of COVID-19, trust in the government, political ideologies, and socio-demographic factors: A year-long cross-sectional study in South Korea.

Risk perception research, targeting the general public, necessitates the study of the multi-faceted aspects of perceived risk through a holistic approach. This study aimed to investigate the association between the two dimensions of risk perception of COVID-19, i.e., risk as a feeling and analysis, trust in the current government, political ideologies, and socio-demographic factors in South Korea. This study used a year-long repeated cross-sectional design, in which a national sample (n = 23,018) participated in 23 consecutive telephone surveys from February 2020 to February 2021. Most factors differed in the magnitude and direction of their relationships with the two dimensions of risk perception. However, trust in the current government, alone, delineated an association in the same direction for both dimensions, i.e., those with a lower level of trust exhibited higher levels of cognitive and affective risk perception. Although these results did not change significantly during the one-year observation period, they are related to the political interpretation of risk. This study revealed that affective and cognitive risk perceptions addressed different dimensions of risk perception. These findings could help governments and health authorities better understand the nature and mechanisms of public risk perception when implementing countermeasures and policies in response to the COVID-19 pandemic and other public health emergencies.

Association Between Self-Rated Political Orientation and Attitude Toward the Cash Transfer Policy During the COVID-19 Pandemic: A Nationwide Cross-Sectional Survey Conducted in South Korea.

Objective: This study assessed the relationship between self-rated political orientation and attitude toward the cash transfer policy during the COVID-19 pandemic. Methods: This cross-sectional study conducted in South Korea during the pandemic included a stratified sample of 1,004 respondents (aged 19 years and older). We tested the hypotheses that political orientation shapes attitudes toward social policies and that other socioeconomic factors might have relatively minor importance. Logistic regression was used to identify associations between political orientation and attitude toward the cash transfer policy. Average marginal effects were calculated to determine the effect size of each variable. Results: Political orientation, age, and residential area were correlated with attitudes toward the policy. Compared to the conservatives, the non-committed and the moderate showed about 10% more favorable attitudes, and the progressive group showed robust support. People in their 30s and 40s showed similar attitudes to the 18-29 group, while older people showed much lower support. Compared to the Seoul metropolitan area, residents of the Ho-nam area showed favorable attitudes, and those of the Yeong-nam area had relatively unfavorable attitudes. Conclusions: This study suggests that attitudes toward the cash transfer policy are mainly associated with political orientation. Although these results illuminate pandemics' social and political dimensions, further efforts are needed to fully understand the determinants and mechanisms of attitudes toward policies outside the traditional health policy scope.

Expanding Medical Surge Capacity to Counteract COVID-19: South Korea's Medical Fee Adjustment Through the National Health Insurance System.

Background: South Korea has utilized its National Health Insurance (NHI) system to adjust the medical fees payable for healthcare services, to financially support the frontline healthcare providers combating COVID-19. This study evaluated the composition of such adjustments to the medical fees-made to secure resource surge capacity against the pandemic-in South Korea. Methods: Descriptive statistics and schematization were employed to analyze 3,612,640 COVID-19-related NHI claims from January 1, 2020, to June 30, 2021. COVID-19 suspected and confirmed cases were evaluated based on the proportion of fees adjustment, classified into space, staff, or stuff (3S) using diagnosis codes. The proportion of fees adjustment was investigated in terms of the healthcare expenditure, number of patients, and number of healthcare services covered. Findings: First, in terms of cost, medical fee adjustments covered over 96% of the total costs arising from the increased demand for testing (stuff) and isolated spaces among patients suspected of having COVID-19. Second, medical fees were adjusted to cover over 80% of the cost attributable to COVID-19 confirmed cases, in relation to isolated spaces and medical staff support. Third, the adjustment of less than 10% of the various types of medical fees, if selected strategically, can effectively induce a surge in resource capacity. Interpretation: South Korea has improved its existing surge capacity by adjusting the medical fees payable through NHI to healthcare providers. Particularly, through the provider payment system of fee-for-service, the Korean government could prevent the spread of infection and protect the medical staff assigned to respond to COVID-19. However, additional studies on alternative payment systems are needed to control costs while maintaining an effective pandemic response system in the face of the prolonged COVID-19 outbreak.

Modified Tumor Budding as a Better Predictor of Lymph Node Metastasis in Early Gastric Cancer: Possible Real-World Applications.

Endoscopic resection (ER) is a minimally invasive treatment for early gastric cancer (EGC) with a low risk of lymph node metastasis (LNM). Recently, tumor budding (TB) has emerged as a potential predictor of LNM in EGC. We assessed the clinical significance of modified TB (mTB) that excludes the signet ring cell component and compared several TB assessment methods. Two hundred and eighty-nine patients with EGC at Uijeongbu St. Mary's Hospital from 2010 to 2021 were enrolled. In univariate analysis, age, size, depth of invasion, tumor type, histologic type, Lauren classification, lymphatic invasion, venous invasion, poorly differentiated carcinoma ("not otherwise specified" predominant), and TB were significantly associated with LNM. Multivariate regression analysis showed that mTB (difference area under the curve [dAUC] = 0.085 and 0.087) was superior to TB (dAUC = 0.054 and 0.057) in predicting LNM. In addition, total TB counts on representative slide sections (dAUC = 0.087 and 0.057) in assessing TB and mTB and the ITBCC method (dAUC = 0.085) in mTB were superior to the presence or absence method (dAUC = 0.042 and 0.029). The mTB significantly increases LNM prediction ability, which can provide important information for patients with EGC.

Political Ideologies, Government Trust, and COVID-19 Vaccine Hesitancy in South Korea: A Cross-Sectional Survey.

This study aimed to assess the correlation between political ideologies, government trust, and COVID-19 vaccine hesitancy in South Korea during the COVID-19 pandemic. A cross-sectional survey was conducted among South Korea's general population and 1000 respondents (aged 18 years and older) were included. We used multivariate logistic regression models to identify the factors associated with vaccine hesitancy. Respondents who self-identified as liberal or held "no political opinion" had higher rates of vaccine hesitancy than conservative respondents. People's trust in the government's countermeasures was associated with vaccination. Respondents who had risk perceptions (affective and cognitive) of COVID-19 had lower rates of vaccine hesitancy. Perceptions that the vaccine was not safe and being aged 18-29, 30-39, or 40-49 were associated with a higher probability of vaccine hesitancy. This study found that even if vaccine safety and risk perceptions toward COVID-19 were adjusted, self-rated political ideologies and government trust was associated with COVID-19 vaccine hesitancy. More effort to communicate with those who are *liberal or "no political opinion", younger, and have lower level of trust in the government are required to dissolve vaccine hesitancy. Further studies should analyze the mechanism of COVID-19 vaccine uptake for effective herd immunity.

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.

New Obligations of Health Insurance Review and Assessment Service: Taking Full-fledged Action Against the COVID-19 Pandemic.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented disruptions to global health systems. The Korea has taken full-fledged actions against this novel infectious disease, swiftly implementing a testing-tracing-treatment strategy. New obligations have therefore been given to the Health Insurance Review and Assessment Service (HIRA) to devote the utmost effort towards tackling this global health crisis. Thanks to the universal national health insurance and state-of-the-art information communications technology (ICT) of the Korea, HIRA has conducted far-reaching countermeasures to detect and treat cases early, prevent the spread of COVID-19, respond quickly to surging demand for the healthcare services, and translate evidence into policy. Three main factors have enabled HIRA to undertake pandemic control preemptively and systematically: nationwide data aggregated from all healthcare providers and patients, pre-existing ICT network systems, and real-time data exchanges. HIRA has maximized the use of data and pre-existing network systems to conduct rapid and responsive measures in a centralized way, both of which have been the most critical tactics and strategies used by the Korean healthcare system. In the face of new obligations, our promise is to strive for a more responsive and resilient health system during this prolonged crisis.

Influence of trust on two different risk perceptions as an affective and cognitive dimension during Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in South Korea: serial cross-sectional surveys.

OBJECTIVES: This study aimed to assess the affective and cognitive risk perceptions in the general population of Middle East respiratory syndrome (MERS) during the 2015 MERS coronavirus (MERS-CoV) outbreak in South Korea and the influencing factors. DESIGN: Serial cross-sectional design with four consecutive surveys. SETTING: Nationwide general population in South Korea. PARTICIPANTS: Overall 4010 respondents (aged 19 years and over) from the general population during the MERS-CoV epidemic were included. PRIMARY AND SECONDARY OUTCOME MEASURES: The main outcome measures were (1) affective risk perception, (2) cognitive risk perception, and (3) trust in the government. Multivariate logistic regression models were used to identify factors (demographic, socioeconomic, area and political orientation) associated with risk perceptions. RESULTS: Both affective and cognitive risk perceptions decreased as the MERS-CoV epidemic progressed. Proportions of affective risk perception were higher in all surveys and slowly decreased compared with cognitive risk perception over time. Females (adjusted OR (aOR) 1.72-2.00; 95% CI 1.14 to 2.86) and lower self-reported household economic status respondents were more likely to perceive the affective risk. The older the adults, the higher the affective risk perception, but the lower the cognitive risk perception compared with younger adults. The respondents who had low trust in the government had higher affective (aOR 2.19-3.11; 95 CI 1.44 to 4.67) and cognitive (aOR 3.55-5.41; 95 CI 1.44 to 9.01) risk perceptions. CONCLUSIONS: This study suggests that even if cognitive risk perception is dissolved, affective risk perception can continue during MERS-CoV epidemic. Risk perception associating factors (ie, gender, age and self-reported household economic status) appear to be noticeably different between affective and cognitive dimensions. It also indicates that trust in the government influences affective risk perception and cognitive risk perception. There is a need for further efforts to understand the mechanism regarding the general public's risk perception for effective risk communication.

General Public's Perspectives on Medical Doctors and Local Clinics in South Korea.

As patients in South Korea play the main role in choosing healthcare providers, understanding their attitudes and beliefs toward medical institutions is essential. This study evaluated the public's perspectives on doctors and local clinics. A face-to-face interview survey was conducted with 1000 participants who represent the South Korean adult population. The questionnaire consisted of four domains: personal information; trust level for nine professionals, including doctors; healthcare utilization behavior and attitudes regarding local clinics; and assessment of local clinics. The trust level of the doctor was highest (3.16 out of 4) among nine professionals. 85.3% of the participants frequently visited local clinics because of accessibility. The main reason for visiting hospitals over local clinics was the belief that doctors employed at hospitals would be better qualified. People were generally satisfied with the service of local clinics but wanted more facilities and equipment. Among six attributes of primary care, "first contact" and "accessibility" got higher scores in importance and current performance. Lastly, the participants suggested that improving the quality of doctors was most important for the reinforcement of primary care. Efforts to consider public opinion should be made before establishing healthcare policies for primary care.

Preventive Behavioral Responses to the 2015 Middle East Respiratory Syndrome Coronavirus Outbreak in Korea.

This study examined the public's preventive behavioral responses during the 2015 Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in Korea and the influencing factors. Two cross-sectional telephone surveys were conducted by Gallup Korea using random digit dialing in June 2015 (n = 2004). The main outcome variables were nonpharmaceutical preventive measures (survey (1): Measures for reducing transmission (handwashing, face masks); and survey (2): Measures for avoiding contact with others). Multiple logistic regression was used to identify the factors influencing preventive behaviors. In survey (1), 60.3% of respondents reported more frequent handwashing and 15.5% reported wearing face masks at least once due to the MERS-CoV epidemic. In survey (2), 41-56% of respondents reported practicing avoidance measures. The concerned group was more likely to practice reducing transmission measures (odds ratio (OR) 4.5; 95% confidence interval (CI) 3.3-6.1) and avoidance measures (OR = 9.6; 95% CI, 6.4-14.4). The respondents who had low trust in president or ruling party had a higher practice rate of reducing transmission measures (OR = 1.7; 95% CI, 1.2-2.6) and avoidance measures (OR = 2.1; 95% CI, 1.2-3.5). Cooperative prevention measures need appropriated public concern based on effective risk communication.

How far is too far? A nationwide cross-sectional study for establishing optimal hospital access time for Korean pregnant women.

OBJECTIVES: Access to a delivery unit is a major factor in determining maternal morbidity and mortality. However, there is little information about the optimal access time to a delivery unit. This study aimed to establish the optimal hospital access time (OHAT) for pregnant women in South Korea. DESIGN: Nationwide cross-sectional study. SETTING: We used the National Health Insurance System database of South Korea. PARTICIPANTS: We analysed the data of 371 341 women who had experienced pregnancy in 2013. PRIMARY AND SECONDARY OUTCOME MEASURES: Access time to hospital was defined as the time required to travel from the patient's home to the delivery unit. The incidence of obstetric complications was plotted against the access time to hospital. Change-point analysis was performed to identify the OHAT by determining a point wherein the incidence of obstetric complications changed significantly. As a final step, the risk of obstetric complications was compared by type among pregnant women who lived within the OHAT against those who lived outside the OHAT. RESULTS: The OHAT associated with each adverse pregnancy outcomes were as follows: inadequate prenatal care, 41-50 min; preeclampsia, 51-60 min; placental abruption, 51-60 min; preterm delivery, 31-40 min; postpartum transfusion, 31-40 min; uterine artery embolisation, 31-40 min; admission to intensive care unit, 31-40 min; and caesarean hysterectomy, 31-40 min. Pregnant women who lived outside the OHAT had significantly higher risk for obstetric complications than those who lived within the OHAT. CONCLUSIONS: Our results showed that the OHAT for each obstetric complication ranged between 31 and 60 min. The Korean government should take the OHAT under consideration when establishing interventions for pregnant women who live outside OHAT to reduce maternal morbidity and mortality.