Factors Associated With Negative Life Changes due to COVID-19 Among Older Adults Residing in an Urban Low-Income Neighborhood in Korea: Focused on Gendered Differences.

This study examined negative life changes due to coronavirus disease of 2019 (COVID-19) and its correlates in a sample of community-dwelling older adults from a low-income urban city in Korea, focusing on gendered differences. Negative life changes due to COVID-19 were categorized into four domains: behavioral/physical, psychosocial, goal-seeking, and control/freedom. Being female, not receiving basic livelihood security, and dissatisfaction with housing situation were significantly associated with negative life changes during the pandemic. Gender-stratified analyses revealed that most within-gender social disparities associated with changes due to COVID-19 occurred in older women. The odds of experiencing negative changes were higher among working women and those receiving security income aid. In low-income urban communities, those who were previously socially and economically active perceived more negative changes owing to the pandemic. The contribution of gender to negative life changes should be considered to effectively alleviate concerns among older adults during pandemics.

Institutional Variance in Mortality after Percutaneous Coronary Intervention for Acute Myocardial Infarction in Korea, Japan, and Taiwan.

BACKGROUND: Although there have been studies that compared outcomes of patients with acute myocardial infarction (AMI) across countries, little focus has been placed on institutional variance of outcomes. The aim of the present study was to compare institutional variance in mortality following percutaneous coronary intervention (PCI) for AMI and factors explaining this variance across different health systems. METHODS: Data on inpatients who underwent PCI for AMI in 2016 were obtained from the National Health Insurance Data Sharing Service in Korea, the Diagnosis Procedure Combination (DPC) Study Group Database in Japan, and the National Health Insurance Research Database (NHIRD) in Taiwan. Multilevel analyses with inpatient mortality as the outcome and the hierarchical structure of patients nested within hospitals were conducted, adjusting for common patient-level and hospital-level variables. We compared the intraclass correlation coefficient (ICC) and the proportion of variance explained by hospital-level characteristics across the three health systems. RESULTS: There were 17 351 patients from 160 Korean hospitals, 29 804 patients from 660 Japanese hospitals, and 10 863 patients from 104 Taiwanese hospitals included in the analysis. Inpatient mortality rates were 6.3%, 7.3%, and 6.0% in Korea, Japan, and Taiwan, respectively. After adjusting for patient and hospital characteristics, Taiwan had the lowest variation in mortality (ICC, 1.8%), followed by Korea (2.2%) and then Japan (4.5%). The measured hospital characteristics explained 38%, 19%, and 9% of the institutional variance in Korea, Taiwan, and Japan, respectively. CONCLUSION: Korea, Japan, and Taiwan had similarly uniform outcomes across hospitals for patients undergoing PCI for AMI. However, Japan had a relatively large institutional variance in mortality and a lower proportion of variation explainable by hospital characteristics, compared with Korea and Taiwan.

Explaining Variations in Long-term Care Use and Expenditures Under the Public Long-term Care Insurance Systems: A Case Study Comparison of Korea and Japan.

BACKGROUND: Establishing universal coverage of formal long-term care (LTC) services is an urgent policy need for aging populations that requires efficient management of quality and financing. Although current variation in LTC service use between and within countries suggests the potential for improvement by efficient management, this topic remains underexamined. We aimed to identify the sources of variance in LTC use and expenditures through a unique cross-country comparison of Japan and South Korea, which have formal public LTC insurance (LTCI) schemes that are analogous but have unique operational and demographic structures. METHODS: Taking administrative regions as the unit of analysis, we assembled data on the LTC utilization rate of people aged ≥65 years, and expenditures per recipient from 2013 to 2015 as the outcome variables. Explanatory variables included demand-related factors, such as regional demographic and economic conditions, and supply characteristics derived from existing public databases. We conducted weighted least squares regression with fixed effects for the pooled data and used Blinder-Oaxaca decomposition to identify sources of outcome variance between the two countries. RESULTS: The average LTC utilization rate was 6.8% in Korea and 18.2% in Japan. Expenditures per recipient were approximately 1.4 times higher in Japan than in Korea. The difference in the utilization rate was mostly explained by between-country differences in supply- and demand-related factors, whereas the difference in expenditures per recipient was largely attributed to unobserved country-specific factors. CONCLUSION: The current findings suggest that LTC utilization is determined largely by the demographic and functional characteristics of older people, whereas expenditures are more likely affected by institutional factors such as the insurance governance scheme and the policy choice of the target population segment and coverage. The results suggest that strategic choice of LTC institutional schemes is required to ensure financial sustainability to meet changing demands caused by population aging.

Does whey protein supplementation during resistance exercise have additional benefits for decreasing hepatic fat content?

BACKGROUND: Exercise and diet have positive effects on hepatic fat reduction, and protein supplementation is known to lower hepatic fat accumulation. However, the effect of a combination of exercise and whey protein supplementation (WPS) on hepatic fat content (HFC) is unknown. METHODS: We investigated the effect of WPS on HFC during resistance exercise and diet control intervention for four weeks. A total of 34 sedentary males participated and were randomly assigned to two groups: a protein supplement group (PSG, n = 18) and a control group (CG, n = 16). The PSG took 60 g of WPS per day, and the CG took 60 g of an isocaloric placebo per day. All participants were fed a calorie-controlled diet throughout the study period, with their daily caloric intake determined by their resting metabolic rate and physical activity level. Both groups performed resistance exercises supervised by experts at 60-70% of their maximum efforts for 60 min/day, 6 days/week for 4 weeks. HFC was assessed using the controlled attenuation parameter (CAP) after an 8 h fast, at pre-, mid-, and post-intervention. Liver enzymes and lipid profile were also analyzed after an 8 h fast and pre- and post-intervention. RESULTS: The CAP was significantly reduced after 4 weeks of intervention in both groups (PSG, p < .001; CG, p = .002). However, there was no significant interaction between the group and changes in CAP. Interestingly, when comparing the pre- and mid-tests, both groups also had significantly reduced CAP (PSG, p = .027; CG, p = .028), but there was a significant difference in the amount of change in CAP between the two groups (PSG, -47.2 ± 25.4 dB/m; CG, -19.5 ± 15.1 dB/m; p = .042). For liver enzymes, there was a significant interaction between the two groups and a change in aspartate transaminase (AST) (p = .038). However, alanine aminotransferase (ALT) levels were significantly decreased only in the PSG group (p = .002). In lipids, both groups showed significantly decreased total cholesterol (p < .001) and low-density lipoprotein cholesterol (p < .001) after the intervention. CONCLUSION: Our data showed that WPS may not enhance the overall effects of resistance exercise on HFC and lipid profiles. However, in part, WPS may have a beneficial effect on liver enzymatic changes and rapid response to resistance exercise-induced HFC reduction.

Urinary Phthalate Metabolites and Slow Walking Speed in the Korean Elderly Environmental Panel II Study.

BACKGROUND: Previous epidemiological studies have suggested that phthalate exposure may contribute to neurocognitive and neurobehavioral disorders and decreased muscle strength and bone mass, all of which may be associated with reduced physical performance. Walking speed is a reliable assessment tool for measuring physical performance in adults age 60 y and older. OBJECTIVE: We investigated associations between urinary phthalate metabolites and slowness of walking speed in community-dwelling adults ages 60-98 y. METHODS: We analyzed 1,190 older adults [range, 60-98 y of age; mean±standard deviation (SD) , 74.81±5.99] from the Korean Elderly Environmental Panel II study and measured repeatedly up to three times between 2012 and 2014. Phthalate exposure was estimated using the following phthalate metabolites in urine samples: mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP), mono-n-butyl phthalate (MnBP), mono-(2-ethyl-5-carboxypentyl) phthalate (MECPP), and mono-benzyl phthalate (MBzP). Slowness was defined as a walking speed of <1.0meter/second. We used logistic and linear regression models to evaluate the association between each urinary phthalate metabolite and slowness or walking-speed change. We also used Bayesian kernel machine regression (BKMR) to examine overall mixture effects on walking speed. RESULTS: At enrollment, MBzP levels were associated with an increased odds of slowness [odds ratio (OR) per doubling increase: 1.15, 95% confidence interval (CI): 1.02, 1.30; OR for the highest vs. lowest quartile: 2.20 (95% CI: 1.12, 4.35) with p-trend across quartiles=0.031]. In longitudinal analyses, MEHHP levels showed an increased risk of slowness [OR per doubling increase: 1.15 (95% CI: 1.02, 1.29), OR for the highest vs. lowest quartile: 1.47 (95% CI: 1.04, 2.06), p- trend=0.035]; whereas those with higher MnBP showed a reduced risk of slowness [OR per doubling increase: 0.84 (95% CI: 0.74, 0.96), OR in the highest (vs. lowest) quartile: 0.64 (95% CI: 0.47, 0.87), p-trend=0.006]. For linear regression models, MBzP quartiles were associated with slower walking speed (p-trend=0.048) at enrollment, whereas MEHHP quartiles were associated with slower walking speed, and MnBP quartiles were associated with faster walking speed in longitudinal analysis (p-trend=0.026 and <0.001, respectively). Further, the BKMR analysis revealed negative overall trends between the phthalate metabolite mixtures and walking speed and DEHP group (MEHHP, MEOHP, and MECPP) had the main effect of the overall mixture. DISCUSSION: Urinary concentrations of prevalent phthalates exhibited significant associations with slow walking speed in adults ages 60-98 y. https://doi.org/10.1289/EHP10549.

Evaluation of a technology-enhanced, integrated community health and wellness program for seniors (HWePS): protocol of a non-randomized comparison trial.

BACKGROUND: Healthy aging for all in the community is a shared public health agenda for countries with aging populations, but there is a lack of empirical evidence on community-wide preventive models that promote the health of older people residing in socially-disadvantaged communities. The Health and Wellness Program for Seniors (HWePS) is a technology-enhanced, multi-level, integrated health equity intervention model. This study evaluates the effect of the HWePS on the health and well-being of older adults residing in urban, low-income communities.  METHODS/DESIGN: HWePS is a prospective, non-randomized comparison trial conducted in an intervention and a control neighborhood (dong) in Seoul, South Korea, over 12 months. Older people who reside in the small areas and meet the inclusion/exclusion criteria are eligible to participate. The multi-level, multi-faceted HWePS intervention is a preventive community care model for older residents guided by the expanded chronic care model, the comprehensive health literacy intervention model, and the Systems for Person-centered Elder Care model along with health equity frameworks. HWePS consists of four components: a health literacy intervention based on individual and community needs assessments, personalized (self-)care management featuring nurse coaching and peer support, a healthy-living and healthy-aging community initiative, and information and communication technology (ICT) systems. The primary outcomes are self-reported health and health-related quality of life. Outcome assessors and data analysts are blinded to group assignment. Process evaluation will be also conducted. DISCUSSION: As a multi-level health equity project, HWePS has adopted a novel study design that simultaneously targets individual- and community-level factors known to contribute to health inequality in later life in the community. The study will provide insights into the effectiveness and implementation process of an integrated, multi-level, preventive community care model, which in turn can help improve the health outcomes of older residents and reduce disparities in underserved urban communities. TRIAL REGISTRATION: ISRCTN29103760. Registered 2 September 2021, https://www.isrctn.com/ISRCTN29103760.

A Pilot Study of Machine Learning-Based Algorithms to Assist Integrated Care for Older Community-Dwelling Adults.

As life expectancy increases, there is a growing consensus on the development of integrated care encompassing the health and daily activities of older adults. In recent years, although the demand for machine learning applications in healthcare has increased, only a few studies have implemented machine learning-based systems in integrated care for older adults owing to the complex needs of older adults and the coarseness of the available data. Our study aims to explore the possibility of implementing machine learning decision-support algorithms in the integrated care of older community-dwelling adults. Our experiment uses secondary data based on the community-based integrated service model. Such data were collected from 511 older adults through 162 assessment items in which tailored services were selected from 18 available services. We implemented four machine learning models: decision tree, random forest, K-nearest neighbors, and multilayer perceptron. The area under the receiver operating characteristic curve results of the four models were decision tree = 0.89, K-nearest neighbors = 0.88, random forest = 0.93, and multilayer perceptron = 0.88. The results suggest that machine learning-based decision-assisting algorithms can improve the quality of tailored services for integrated care with intensive involvement of face-to-face tasks by reducing the simple, repetitive tasks of care managers.

Analysis of blood pressure and blood pressure variability pattern among older patients in long-term care hospitals: an observational study analysing the Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) dataset.

OBJECTIVES: There are limited data regarding blood pressure (BP) variability among older adults living in long-term care hospitals (LTCHs). We aimed to collect data from LTCH and analyse BP characteristics and its variability among these patients using a novel platform. METHODS: The Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) platform was used to construct a daily BP dataset using data of 394 older patients from 6 LTCHs. BP variability was expressed as coefficient of variation (CV = standard deviation/mean of BP × 100). Physical frailty and cognitive function were evaluated using the K-FRAIL questionnaire and the Cognitive Performance Scale of the interRAI Long-Term Care Facilities tool, respectively. RESULTS: From September 2019 to September 2020, 151,092 BP measurements, 346.5 (IQR 290.8-486.3) measurements per patient, were included. The mean BP was 123.4 ± 10.8/71.3 ± 6.5 mmHg. BP was significantly lower in frail patients (122.2 ± 11.3/70.4 ± 6.8 mmHg) than in pre-frail/robust patients (124.4 ± 10.4/72.1 ± 6.1 mmHg, P < 0.05). However, CV of systolic (10.7 ± 2.3% versus 11.3 ± 2.3%, P = 0.005) and diastolic (11.6 ± 2.3% versus 12.4 ± 2.4%, P < 0.001) BP was higher in frail patients. The mean BP was lower, but BP variability was higher in patients with cognitive impairment. The mean BP, but not BP variability, was higher in treated hypertensive patients, as the number of antihypertensive medications increased. CONCLUSION: Older patients with physical or cognitive frailty had lower BP but higher BP variability. Relationship among frailty, increased BP variability and adverse clinical outcomes should be investigated.

Factors associated with anticholinergic burden among older patients in long-term care hospitals in Korea.

BACKGROUND/AIMS: Drugs with anticholinergic properties (DAPs) are associated with adverse health outcomes in older patients. The objective of this study was to evaluate the factors that determine the prescribing of more DAPs in long-term care hospitals (LTCHs) in Korea. In addition, the current patterns of DAP prescription were explored using a novel platform, which can collect data from LTCHs. METHODS: This was a Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) sub-study, which is a pragmatic, cluster-randomized, controlled trial. The Health-RESPECT platform was used to collect prescribed medication data of 466 patients (aged ≥ 65 years) from seven LTCHs. DAPs were identified using the Korean Anticholinergic Burden Scale (KABS). Physical frailty, cognitive function, functional status, and quality of life were evaluated. RESULTS: Among 466 LTCH patients, 88.8% (n = 414) were prescribed DAPs, and the prevalence of high KABS (≥ 3) was 70.4% (n = 328). The drugs that contributed most to the total KABS were quetiapine (20.7%), chlorpheniramine (19.5%), tramadol (9.8%), cimetidine (5.8%), and furosemide (3.6%). Polypharmacy, higher body mass index, less dependence, better communication and cognitive functions, and poorer quality of life were associated with high KABS. CONCLUSION: Although the patients with a high burden of DAPs were less dependent and had better cognitive and communication functions, they had poorer quality of life. DAP use in LTCH patients should be monitored carefully, and the risk/ benefit relationship for their use should be considered.

Factors Associated With Low and High Social Engagement Among Older Nursing Home Residents in Korea.

OBJECTIVES: With the increase in older adults receiving long-term care in facilities, the level of social engagement within nursing homes is a growing concern for improving the quality of life of residents. This study seeks to assess the level of social engagement and identify the factors associated with high and low engagement among older adults in Korean nursing homes. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Data were obtained from a nationally representative sample of 1453 older residents in 92 long-term care facilities across Korea. METHODS: Multilevel-multivariate analyses were carried out to identify individual- and institution-level risk factors of social engagement, as measured by the Revised Index of Social Engagement (RISE). RESULTS: Three-fourths of older residents had a low level of social engagement, whereas only about one tenth showed a high level of social engagement. Being male, having severe functional impairments, having depression, and having no supportive family relationships were risk factors for low social engagement. Conversely, a high level of social engagement was significantly associated with being female, having no impairments, and a longer length of stay. Meeting staffing requirements for personal care assistants, an institution-level factor, was negatively associated with low social engagement and positively associated with high social engagement. CONCLUSIONS AND IMPLICATIONS: Low social engagement is very common in Korean nursing homes and is concentrated among those with poor functional and social outcomes. Future efforts to improve long-term care will need to address the various factors associated with social engagement in designing social care for nursing home residents.

Efficacy and Safety of Tenofovir Disoproxil Orotate in Chronic Hepatitis B Patients Previously Treated with Tenofovir Disoproxil Fumarate: Multicenter, Open-Label, Prospective Study.

BACKGROUND/AIM: We aimed to demonstrate the efficacy and safety of tenofovir disoproxilorotate (TDO) compared with that of tenofovir disoproxil fumarate (TDF) in patients with chronic hepatitis B. METHODS: This multicenter, open-label, prospective clinical trial (KCT0004185) was conducted to evaluate the efficacy and safety of TDO on switching from TDF for 24 weeks in virologically suppressed chronic hepatitis B patients. The primary efficacy endpoint was the maintenance of virologic response. Safety was assessed by evaluating major adverse events, changes in renal function, and occurrence of hepatocellular carcinoma (HCC). RESULTS: TDO treatment was not inferior in terms of virological response when compared with that on TDF treatment, with a noninferiority margin of -10% (risk difference, -3.17%; 95% confidence interval, -7.5%-1.15%). The biological response of TDO was also comparable to that of TDF, with no significant difference in the proportion of patients with normalized alanine transaminase levels. After 24 weeks of treatment, hepatitis B core-related antigen (HBcrAg) significantly decreased to a mean titer of 3.91 log U/mL from 4.15 log U/mL at baseline (p = 0.01). There were no cases of grade 3 or higher adverse events and HCC. The mean estimated glomerular filtration rate increased from 91.09 mL/min to 93.34 mL/min (p = 0.056), and the mean serum level of phosphorus increased from 3.33 mg/dL to 3.44 mg/dL (p = 0.045), suggesting improvement in renal function with TDO treatment. CONCLUSION: In patients with chronic hepatitis B, the efficacy of TDO was noninferior to that of TDF, with a significant decrease in the HBcrAg titer and improved renal function.

Variations in hip fracture inpatient care in Japan, Korea, and Taiwan: an analysis of health administrative data.

BACKGROUND: Little is known about hip fracture inpatient care in East Asia. This study examined the characteristics of patients, hospitals, and regions associated with delivery of hip fracture surgeries across Japan, Korea, and Taiwan. We also analyzed and compared how the resource use and a short-term outcome of the care in index hospitals varied according to factors in the respective health systems. METHODS: We developed comparable, nationwide, individual-level health insurance claims datasets linked with hospital- and regional-level statistics across the health systems using common protocols. Generalized linear multi-level analyses were conducted on length of stay (LOS) and total cost of index hospitalization as well as inpatient death. RESULTS: The majority of patients were female and aged 75 or older. The standardized LOS of the hospitalization for hip fracture surgery was 32.5 (S.D. = 18.7) days in Japan, 24.7 (S.D. = 12.4) days in Korea, and 7.1 (S.D. = 2.9) days in Taiwan. The total cost per admission also widely varied across the systems. Hospitals with a high volume of hip fracture surgeries had a lower LOS across all three systems, while other factors associated with LOS and total cost varied across countries. CONCLUSION: There were wide variations in resource use for hip fracture surgery in the index hospital within and across the three health systems with similar social health insurance schemes in East Asia. Further investigations into the large variations are necessary, along with efforts to overcome the methodological challenges of international comparisons of health system performance.

Implementation fidelity of the Systems for Person-Centered Elder Care (SPEC): a process evaluation study.

BACKGROUND: The Systems for Person-Centered Elder Care (SPEC), a complex intervention, was conducted to examine its effectiveness as a technology-enhanced, multidisciplinary, and integrated care model for frail older persons among ten nursing homes (NHs) in South Korea where formal long-term care has recently been introduced. The purpose of this study was to evaluate the implementation fidelity of the SPEC intervention and to identify moderating factors that influence the implementation fidelity. METHODS: This study was a process evaluation based on an evidence-based framework for implementation fidelity using a mixed-methods design. Quantitative data from consultant logbooks, NH documentations, an information and communications technology (ICT) system, and a standardized questionnaire were collected from April 2015 to December 2016 and analyzed by calculating the descriptive statistics. Semi-structured focus group interviews were held with multidisciplinary teams from the participating NHs. Qualitative data from a semi-structured questionnaire and the focus group interviews were analyzed using content analysis. RESULTS: The SPEC program demonstrated good implementation fidelity, and adherence to the SPEC program was strong in all aspects, such as content, coverage, frequency, and duration. Of the participating on-site coordinators, 60% reported that the SPEC model positively impacted needs assessment and the reporting system for resident care. The important facilitating factors were tailored facilitating strategies, assurance of the quality of delivery, and recruitment strategies. CONCLUSION: The effectiveness of the SPEC program was driven by good implementation fidelity. The key factors of good implementation fidelity were tailored delivery of evidence-based interventions over process evaluation work, facilitating strategies, and ICT support. Larger implementation studies with a more user-friendly ICT system are recommended. TRIAL REGISTRATION: ISRCTN registry, ISRCTN11972147 . Registered on 16 March 2015.

Association between Phthalate Exposure and Frailty among Community-Dwelling Older Adults: A Repeated Panel Data Study.

Only a few studies have examined the impacts of environmental exposure on frailty. This study investigated the association between phthalates and frailty among community-dwelling older adults. The Korean Elderly Environmental Panel II (KEEP II) study is a repeated panel data study of 800 community-dwelling older adults in South Korea. Frailty was measured with five items defined by Fried and colleagues. Environmental pollutants in the form of two types of metabolites for Di-ethylhexyl phthalate (DEHPs)-Mono (2-ethyl-5-hydroxyhexyl) phthalate (MEHHP) and Mono (2-ethyl-5-oxohexyl) phthalate (MEOHP)-were obtained from urine specimens. Analyses were performed using repeated linear mixed models. The concentration levels of both MEOHP and MEHHP in urine were significantly higher in the pre-frail or frail group than its counterparts. While adjusting for covariates, MEOHP level was positively associated with the likelihood of being pre-frail or frail in both males and females; the concentration level of MEHHP also had a positive impact on the likelihood of being pre-frail or frail in females. The DEHP metabolite concentrations were significantly lower among adults with daily fruit consumption in both males and females. DEHPs, measured by metabolite concentrations, may increase the risk of frailty among older men and women; further studies are necessary. The preventive effects of nutrition on DEHP risk should also be further investigated.

Effectiveness of a Technology-Enhanced Integrated Care Model for Frail Older People: A Stepped-Wedge Cluster Randomized Trial in Nursing Homes.

BACKGROUND AND OBJECTIVES: The objective of this study was to evaluate the impact of an information and communication technologies (ICT)-enhanced, multidisciplinary integrated care model, called Systems for Person-centered Elder Care (SPEC), on frail older adults at nursing homes. RESEARCH DESIGN AND METHODS: SPEC was implemented at 10 nursing homes in South Korea in random order using a stepped-wedge design. Data were collected on all participating older residents in the homes before the first implementation and until 6 months after the last implementation. The 21-month SPEC intervention guided by the chronic care model (CCM) consists of 5 strategies: comprehensive geriatric assessment, care planning, optional interdisciplinary case conferences, care coordination, and a cloud-based ICT tool along with a free messaging app. The primary outcome was quality of care measured by a composite quality indicator (QI) from the interRAI assessment system. Usual care continued over the control periods. Nursing home staff were not blinded to the intervention. RESULTS: There were a total of 482 older nursing home residents included in the analysis. Overall quality of care measured by the composite QI was significantly improved (adjusted mean difference: -0.025 [95% CI: -0.037 to -0.014, p < .0001]). The intervention effect was consistent in the subgroup analysis by cognition and activities of daily living. There were no important adverse events or side effects. DISCUSSION AND IMPLICATIONS: The SPEC, a CCM-guided, ICT-supported, multidisciplinary integrated care management intervention, can improve the quality of care measured by health and functional outcomes for frail older persons residing in nursing homes with limited health care provision. CLINICAL TRIALS REGISTRATION NUMBER: ISRCTN11972147.

A decade of public long-term care insurance in South Korea: Policy lessons for aging countries.

South Korea proactively introduced public long-term care insurance (LTCI) in 2008 when older people were only about one-tenth of the total population. At that time, Korea switched from a tax-based, local-government-operated LTC program targeting low-income older people to the current universal public LTCI run by the National Health Insurance Service, the single public insurer. The LTCI program provides a comprehensive package of home- and institution-based care mainly targeting older people who need assistance in daily living. Over the past decade, the program has continued to expand its population and service coverage: older people in high need have been covered, and an infrastructure for service provision has been established. Future agendas include financial sustainability, care coordination, and the role of local governments. Korea's experiences suggest having an LTCI separate from the NHI has the benefit of potential de-medicalization of LTC, which, in turn, creates challenges for the coordination of health care and LTC. A centralized LTCI system with a single payer has the benefit of bigger risk-pooling, but this may become a barrier to designing integrated community care systems at the local level. There is a tradeoff between population coverage, benefits/cost coverage, and fiscal sustainability.

Validation of an integrated service model, Health-RESPECT, for older patients in long-term care institution using information and communication technologies: protocol of a cluster randomised controlled trial.

INTRODUCTION: There is an increased healthcare need to manage institutionalised older patients owing to the ageing population. To overcome substantial future challenges, the Health-RESPECT (caRE Systems for Patients/Elderly with Coordinated care using icT), a new information and communication technologies based integrated management service model, was developed to provide effective management, enable consultation with distant professionals and share medical information between acute care hospitals and long-term care institutions. METHODS AND ANALYSIS: A cluster randomised controlled trial will be conducted to examine the effectiveness of the Health-RESPECT in older patients with chronic diseases and their medical staff in charge. Intervention involves registration with simple comprehensive geriatric assessment, establishment of an individualised care plan for three chronic diseases (hypertension, diabetes and heart failure), medication and rehabilitation management, periodic video-conference and in-system assessment after intervention period. Primary outcomes are control levels of the three chronic diseases, adequacy of drug management and overall functional status. Patients will be assessed at before and after study period and 3 months after study ended. Analysis will be carried out with an intention-to-treat principle. In addition to evaluate intervention effects, clinical usability and economic evaluation will be assessed. ETHICS AND DISSEMINATION: The study protocol was reviewed and approved by the Seoul National University Bundang Hospital Institutional Review Board. Study findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: KCT0004360.

Development of Health-RESPECT: An Integrated Service Model for Older Long-Term Care Hospital/Nursing Home Patients Using Information and Communication Technology.

BACKGROUND: Korea, as one of the fastest-aging countries worldwide, requires an improved healthcare service model for older adults. We evaluated the current healthcare system and developed a service model based on information and communication technologies (ICT) for use in older patients in long-term care facilities (LTCF). METHODS: We conducted a qualitative literature review, focus group interviews (FGIs), and structured survey to identify the current technology use and status of healthcare systems. We then developed a web-based platform with necessary, high-priority, and usable content for the care of older patients in LTCF. RESULTS: We reviewed 60 (23 hypertension, 18 diabetes, and 19 heart failure) articles on information and communication technologies (ICT)-based disease management for clinical effectiveness and improved patient satisfaction. FGIs and structured surveys were used to evaluate the inconvenience in patient and medical information transfer between hospitals and cost and time required for its process. Accordingly, we confirmed the unmet need for an ICT-based service model for management, monitoring, and consultation among older patients and developed the Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT), a service platform for older patients residing in LTCF. The medical information exchange system was used to transfer medical information. Health-RESPECT includes an established algorithm for evidence-based comprehensive geriatric assessment and customized management; chronic disease management; management of potentially inappropriate medications; rehabilitation; and consultation and videoconferencing. CONCLUSION: This study identified the current status and unmet needs of healthcare systems for older adults. We developed an ICT-based system to manage older institutionalized patients. However, the Health-RESPECT service model requires further validation.

Developing a framework for performance assessment of the public long-term care system in Korea: methodological and policy lessons.

BACKGROUND: Limited evidence exists on how to assess long-term care system performance. This study aims to report on the process and results of developing a performance assessment framework to evaluate the long-term care system financed by the public long-term care insurance in South Korea. METHODS: The framework was developed through a six-step approach, including setting the goals and scope of performance assessment in the given policy context, reviewing existing performance frameworks, developing a framework with a wide range of potential indicators, refining the framework through a series of Delphi surveys and expert meetings, examining the feasibility of generated indicators through a pilot test, receiving the comments of stakeholders, and finalising the performance framework. RESULTS: The finalised framework has 4 domains - coverage, quality of care, quality of life and system sustainability - and 28 indicators, including 10 core indicators to monitor long-term care system performance. Usability and feasibility along with policy relevance were important criteria in selecting these indicators. The proposed framework can be used to assess the performance of the long-term care system in Korea, and the framework and its methodological approach can be benchmarks for other countries developing their own framework. CONCLUSIONS: It is critical to reconcile and prioritise various stakeholders' views and information needs as well as to balance methodological rigor with practical usefulness and feasibility in the development and implementation of a long-term care performance monitoring system.

Cluster-specific nonignorably missing, endogenous, and continuous regressors in multilevel model for binary outcome.

In multilevel regression models for observational clustered data, regressors can be correlated with cluster-level error components, namely endogenous, due to omitted cluster-level covariates, measurement error, and simultaneity. When endogeneity is ignored, regression coefficient estimators can be severely biased. To deal with endogeneity, instrument variable methods have been widely used. However, the instrument variable method often requires external instrument variables with certain conditions that cannot be verified empirically. Methods that use the within-cluster variations of the endogenous variable work under the restriction that either the outcome or the endogenous variable has a linear relationship with the cluster-level random effect. We propose a new method for binary outcome when it follows a logistic mixed-effects model and the endogenous variable is normally distributed but not linear in the random effect. The proposed estimator capitalizes on the nested data structure without requiring external instrument variables. We show that the proposed estimator is consistent and asymptotically normal. Furthermore, our method can be applied when the endogenous variable is missing in a cluster-specific nonignorable mechanism, without requiring that the missing mechanism be correctly specified. We evaluate the finite sample performance of the proposed approach via simulation and apply the method to a health care study using a San Diego inpatient dataset. Our study demonstrates that the clustered structure can be exploited to draw valid analysis of multilevel data with correlated effects.