Economic evaluation of acupuncture as an adjunctive treatment with usual care for mild-to-moderate knee osteoarthritis: A Markov model-based analysis.

Background: Collaborative care (CC), in which acupuncture is combined with usual care (UC), improves clinical outcomes and increases costs in knee osteoarthritis (KOA). We evaluated the economic feasibility of CC for Korean female patients with mild-to-moderate KOA by using a cost-effectiveness approach. Methods: Two alternatives for KOA (1. UC as a comparator; and 2. CC as an intervention) were defined based on clinical guidelines, official Korean statistics, and expert validation. Each alternative was simulated in a Markov model every 6 months for 10 years. Estimates of costs, utilities, and transition probabilities were obtained from official statistics and previous studies. The effectiveness of CC was synthesized from randomized controlled trials. A base-case analysis of a limited societal perspective, univariate sensitivity analysis, and probability sensitivity analysis were performed. An annual discount rate of 4.5% and threshold of 20,000 United States dollar per Quality-adjusted life year (USD/QALY) were applied. Results: Every incremental cost-effectiveness ratio (ICER) of CC calculated from the analyses was sub-threshold. In the base-case analysis, with a limited societal perspective, the ICER was 11,085 USD/QALY. The ICERs from the univariate sensitivity analyses were -2,577-16,748 USD/QALY. The average ICER in the probability sensitivity analysis was 12,412 USD/QALY. When the threshold surpassed 8,000 USD/QALY, the cost-effectiveness of CC exceeded 50%. The probability was 70.27% when the threshold was 20,000 USD/QALY. Conclusions: CC for Korean female patients with mild-to-moderate KOA was generally cost-effective. Considering the limitations of the evidence, we propose a re-evaluation using further clinical studies in the future.

Evaluation of the effectiveness of the standard traditional Korean medicine-based health promotion program for disadvantaged children in South Korea.

BACKGROUND: Traditional Korean Medicine (TKM) is highly integrated with the modern health care system of South Korea and is actively used in the public health field. Since 2014, the Ministry of Health and Welfare of South Korea has supported the development of standard models for TKM-based health promotion programs. This study aimed to develop and evaluate a standard TKM-based health promotion program for disadvantaged children. METHODS: Using convenience sampling, we recruited 16 Community Children's Centers (CCCs) located in Busan and Yangsan, South Korea, which are welfare daytime facilities for children from socially disadvantaged families. The CCCs were divided into two groups of eight CCCs-intervention CCCs and control CCCs-through random allocation, and children in each group were selected as subjects for the study. For 12 weeks, the TKM-based health promotion program developed in this study along with the basic services of CCCs were applied to children in the intervention group, and only the basic services of CCCs were provided to children in the control group. Data were obtained through pre- and post-surveys with the legal representatives of the children prior to implementing the program and after the 12-week program, respectively. The outcome variables-the number of outpatient visits, absences, lateness/early leaves, infectious symptoms, and EuroQol-5D and EQ-visual analog scale scores-were measured and statistically compared between the groups by descriptive analysis, chi-square test, t-test, and difference-in-differences model with regression analysis. RESULTS: At baseline, there were 156 children in the intervention group and 153 children in the control group, among which 155 and 147 children, respectively, were included in the analysis. Results indicated that the number of outpatient visits was significantly lower (by 65%) in the intervention group than in the control group (p = 0.03), and this was similar in the sensitivity analysis. Regarding other outcome variables, the effects were not consistently significant. CONCLUSIONS: A standard TKM-based health promotion program has the potential to improve the health of disadvantaged children. In the future, studies with long-term interventions and a larger sample are needed to enhance the applicability of these programs in communities.

The process of National Health Insurance coverage for Chuna Manual Therapy in Korea: A qualitative study.

BACKGROUND: Chuna Manual Therapy (CMT) has been widely used in Korea, and coverage in Korean National Health Insurance (NHI) was finally implemented in 2019. The objectives of this study were to analyze the process of NHI coverage for CMT qualitatively, and to summarize important roles, streams, and implications regarding its inclusion in the modern public health insurance system. METHODS: Related literature was collected and 8 key personnel involved in the policy-making process were qualitatively interviewed, and Zahariadis' version of the Multiple Streams Framework (MSF) was applied to analyze the policy agenda setting and the roles of stakeholders. RESULTS: Through the collaborative efforts of various stakeholders, a pilot coverage project for CMT was implemented in 2017, and coverage was expanded nationwide in 2019. MSF showed that it was mainly achieved through three streams: governmental change (political stream), demand from the general public and KM doctors (problem stream), and strengthening/reinforcement of the feasibility and acceptability of the policy (policy steam). Also, the roles of policy entrepreneurs and resulting changes were shown to be significant for the overall process. CONCLUSION: NHI coverage for CMT was realized through collective policy and research efforts from the government and academic sectors. The roles of stakeholders were shown to be significant in the overall process, and documentation of their involvement is hoped to be of use of other countries that utilize traditional and/or manual medicine.

A comparative study of the traditional medicine systems of South Korea and Taiwan: Focus on administration, education and license.

BACKGROUND: Traditional medicine (TM) is widely used in South Korea and Taiwan, and both societies have similar systems for the management of TM. This study aimed to compare the TM systems in South Korea and Taiwan. METHODS: We searched for studies on the TM systems and collected statistical data from the websites of relevant government agencies in both countries. Interviews were conducted with experts on TM and officials from government agencies. The two TM systems were described and examined in terms of policies, resources, utilization, licensing, and educational systems. RESULTS: Both South Korea and Taiwan have a dual system that separates the administration, licensing and educational systems between TM and Western Medicine (WM), and the TM systems are well established and highly standardized. Comparing with South Korea, however, Taiwan has a more flexible dual medical system in which education courses for producing dual licensure are provided. Additionally, in the system in Taiwan, dual license holders can use both TM and WM methods without limitations and WM doctors can apply acupuncture under some circumstances. Because of the strict dual medical system in South Korea, TM and WM conflict with each other on most health issues. CONCLUSION: Both South Korea and Taiwan have the advantages of preserving TM, as TM and WM are systemically independent and together provide a more holistic approach. The institutionalization of TM in South Korea and Taiwan may be a good reference for countries considering modernization of their TM.

Factors related to the parallel use of complementary and alternative medicine with conventional medicine among patients with chronic conditions in South Korea.

BACKGROUND: This study aims to examine the characteristics and behavioral patterns of patients with chronic conditions behind their parallel use of the conventional medicine (CM) and the complementary and alternative medicine (CAM) that includes traditional Korean Medicine (KM). METHODS: This cross-sectional study used the self-administered anonymous survey method to obtain the results from inpatients who were staying in three hospitals in Gyeongnam province in Korea. RESULTS: Of the 423 participants surveyed, 334 participants (79.0%) used some form of CAM among which KM therapies were the most common modalities. The results of a logistic regression analysis showed that the parallel use pattern was most apparent in the groups aged over 40. Patients with hypertension or joint diseases were seen to have higher propensity to show the parallel use patterns, whereas patients with diabetes were not. In addition, many sociodemographic and health-related characteristics are related to the patterns of the parallel use of CAM and CM. CONCLUSION: In the rural area of Korea, most inpatients who used CM for the management of chronic conditions used CAM in parallel. KM was the most common in CAM modalities, and the aspect of parallel use varied according to the disease conditions.

Relationship between patient satisfaction with medical doctors and the use of traditional Korean medicine in Korea.

BACKGROUND: Satisfaction with medical doctor (MD) has been studied as a possible motivation for trying complementary medicine. This study aimed to explore the relationship between Korean outpatients' satisfaction with their MDs and their use of traditional Korean medicine (KM). METHODS: Data were drawn from the 2011 annual Korea Health Panel, a national representative sample. We analyzed the relationship between outpatients' use of KM and outpatients' satisfaction with MDs by using the responses of 9,753 outpatients, including 1,946 KM outpatients. The Andersen behavior model was applied to select the variables. The validity and reliability of the questionnaires were tested by Factor Analysis and Cronbach's alpha. Multiple logistic regression was used to evaluate five MD satisfaction indicators (patient's trust in MD, MD's careful listening, MD's sufficient explanation, MD's consultation time, and MD's respect for patient) and the overall satisfaction with the MD. RESULTS: There was no significant difference between the MD satisfaction of KM users and that of nonusers in any of the 5 indicators of MD satisfaction. When we controlled for all independent variables from the Anderson behavior model, however, the patients' overall dissatisfaction with MDs was associated with their use of KM (OR = 0.87,0.76-0.99). In addition, the more a patient was dissatisfied with the consultation time of their MD, the more they used KM (OR = 0.82, 072-0.94). CONCLUSIONS: Patients who were dissatisfied with their MD were more likely to use KM; the main indicator affecting MD dissatisfaction was the relatively short time of MD consultations. This could be one reason why KM plays a complementary role with conventional medicine in Korea.

How current Clinical Practice Guidelines for low back pain reflect Traditional Medicine in East Asian Countries: a systematic review of Clinical Practice Guidelines and systematic reviews.

OBJECTIVES: The aims of this study were to investigate whether there is a gap between evidence of traditional medicine (TM) interventions in East-Asian countries from the current Clinical Practice Guidelines (CPGs) and evidence from current systematic reviews and meta-analyses (SR-MAs) and to analyze the impact of this gap on present CPGs. METHODS: We examined 5 representative TM interventions in the health care systems of East-Asian countries. We searched seven relevant databases for CPGs to identify whether core CPGs included evidence of TM interventions, and we searched 11 databases for SR-MAs to re-evaluate current evidence on TM interventions. We then compared the gap between the evidence from CPGs and SR-MAs. RESULTS: Thirteen CPGs and 22 SR-MAs met our inclusion criteria. Of the 13 CPGs, 7 CPGs (54%) mentioned TM interventions, and all were for acupuncture (only one was for both acupuncture and acupressure). However, the CPGs did not recommend acupuncture (or acupressure). Of 22 SR-MAs, 16 were for acupuncture, 5 for manual therapy, 1 for cupping, and none for moxibustion and herbal medicine. Comparing the evidence from CPGs and SR-MAs, an underestimation or omission of evidence for acupuncture, cupping, and manual therapy in current CPGs was detected. Thus, applying the results from the SR-MAs, we moderately recommend acupuncture for chronic LBP, but we inconclusively recommend acupuncture for (sub)acute LBP due to the limited current evidence. Furthermore, we weakly recommend cupping and manual therapy for both (sub)acute and chronic LBP. We cannot provide recommendations for moxibustion and herbal medicine due to a lack of evidence. CONCLUSIONS: The current CPGs did not fully reflect the evidence for TM interventions. As relevant studies such as SR-MAs are conducted and evidence increases, the current evidence on acupuncture, cupping, and manual therapy should be rigorously considered in the process of developing or updating the CPG system.

Medical practices and attitudes of dual-licensed medical doctors in Korea.

Unique dual medical system in Korea has resulted in the emergence of dual-licensed medical doctors (DLMDs) who have both traditional Korean medicine (KM) and Western medicine (WM) licenses. There have been few studies on DLMDs in spite of their growing number and importance within the medical system. We surveyed the current status and attitudes of DLMD to assess their role in integrative medicine. Questionnaires were administered to the members of the association of DLMD. Data from 103 DLMD were collected and statistically analyzed. 41.4% of DLMD were copracticing both WM and KM at a single clinic, preferring the WM approach for physical examinations, laboratory tests, and education for patients-and the KM approach for treatment and prescription. Musculoskeletal, gastroenterologic, and allergic diseases were considered to be effectively treated with co-practice. DLMD highly agreed on the efficiency of copractice for disease control and patients' satisfaction. On the other hand, they regarded the lack of health insurance coverage for copractice and increased medical expenditure as major problems in providing co-practice. To expand the role of DLMD as mediators of integration in primary health care, the effectiveness of their co-practice should be evaluated and a corresponding health insurance reimbursement system should be established.

Korean medicine coverage in the National Health Insurance in Korea: present situation and critical issues.

National Health Insurance (NHI) in Korea has covered Korean medicine (KM) services including acupuncture, moxibustion, cupping, and herbal preparations since 1987, which represents the first time that an entire traditional medicine system was insured by an NHI scheme anywhere in the world. This nationwide insurance coverage led to a rapid increase in the use of KM, and the KM community became one of the main interest groups in the Korean healthcare system. However, due to the public's safety concern of and the stagnancy in demand for KM services, KM has been facing new challenges. This paper presents a brief history and the current structure of KM health insurance, and describes the critical issues related to KM insurance for in-depth understanding of the present situation.

Traditional medicine in china, Korea, and Japan: a brief introduction and comparison.

Background and Purpose. Traditional medicine (TM) has been widely used in China (including the Taiwan region), Korea, and Japan. The purposes of this paper are to summarize the basic data on TM systems in these three countries and to compare them in terms of overall policy, education, and insurance. Methods. Government websites, national statistics, and authoritative papers from each country were fully searched. Further data were gathered by TM experts from each country. Results. China and Korea showed similar patterns in TM systems, whereas Japan showed different patterns. In China and Korea, TM was practiced in a dual system with conventional medicine (CM), and TM education was 6-year training programs on average for TM doctors, and acupuncture, moxibustion, and cupping were completely insured. Whereas, CM was dominant in Japan, and TM was practiced by each health care worker who has received different TM education respectively, and main TM therapies were partially insured. Conclusions. TM was developed similarly or somewhat differently based on differences in cultural background and national policies in East Asia. We cautiously propose that this study could contribute to the development of TM and also be used for reference in complementary and alternative medicine systems.

Attempts to utilize and integrate traditional medicine in North Korea.

AIM: To summarize the way North Korea attempted to modernize its system of traditional medicine and integrate it with Western biomedicine. METHODS: We reviewed clinical textbooks and periodicals of traditional Korean medicine published in North Korea, research reports on North Korean health and medicine published elsewhere, and conducted interviews of defectors from North Korea who were students or clinicians of traditional medicine. RESULTS: Key findings of this study are: (1) North Korea has attempted several ways of integrating traditional medicine into education and clinical practices; (2) North Korea's communist government provided the main driving force for an integration policy; (3) school curricula of both Western and traditional Korean medicine incorporated knowledge of both disciplines, yet more weight was placed on traditional Korean medicine; (4) a combination of Western diagnosis and Korean therapeutics was the most frequent example of integration, while the dual system approach with reciprocal practice was also explored; (5) several forms of integrative therapeutic mixture were practiced including concurrent medication, injection on acupuncture points, and intramuscular or intravenous injection of extracts from medicinal plants; and (6) limited resources for research and the underdeveloped level of clinical research failed to secure rigorous scientific advancement. CONCLUSIONS: Despite the government-driven attempt to create an ideal integrative system of medicine, according to our findings, the actual introduction of an integrative system into practice was far from the North Korean government's anticipated outcome in regards to clinical practice. We hypothesize this was due to famine, economic crisis, and political isolation from the international realm. Traditional Korean medicine seems to have served the population, which is in desperate need of treatment amid difficulties in health, while North Korea's Western biomedicine-based health delivery system has been badly affected.

Acupuncture for knee osteoarthritis--a randomised trial using a novel sham.

BACKGROUND: Evidence on the efficacy of acupuncture for reducing the pain and dysfunction of osteoarthritis is equivocal. OBJECTIVE: To determine whether acupuncture provides greater pain relief and improved function compared with sham acupuncture or education in patients with osteoarthritis of the knee. DESIGN: Randomised, controlled trial. SETTING: Two outpatient clinics (an integrative medicine facility and a rheumatology facility) located in academic teaching hospitals and one clinical trials facility. PATIENTS: 570 patients with osteoarthritis of the knee (mean age [+/-SD], 65.5 +/- 8.4 years). INTERVENTION: 23 true acupuncture sessions over 26 weeks. Controls received 6 two-hour sessions over 12 weeks or 23 sham acupuncture sessions over 26 weeks. MEASUREMENTS: Primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at 8 and 26 weeks. Secondary outcomes were patient global assessment, 6-minute walk distance, and physical health scores of the 36-Item Short-Form Health Survey (SF-36). RESULTS: Participants in the true acupuncture group experienced greater improvement in WOMAC function scores than the sham acupuncture group at 8 weeks (mean difference, -2.9 [95% CI, -5.0 to -0.8]; P=0.01) but not in WOMAC pain score (mean difference, -0.5 [CI, -1.2 to 0.2]; P=0.18) or the patient global assessment (mean difference, 0.16 [CI, -0.02 to 0.34]; P> 0.2). At 26 weeks, the true acupuncture group experienced significantly greater improvement than the sham group in the WOMAC function score (mean difference, -2.5 [CI, -4.7 to -0.4]; P=0.01), WOMAC pain score (mean difference, -0.87 [CI, -1.58 to -0.16]; P=0.003), and patient global assessment (mean difference, 0.26 [CI, 0.07 to 0.45]; P=0.02). LIMITATIONS: At 26 weeks, 43% of the participants in the education group and 25% in each of the true and sham acupuncture groups were not available for analysis. CONCLUSIONS: Acupuncture seems to provide improvement in function and pain relief as an adjunctive therapy for osteoarthritis of the knee when compared with credible sham acupuncture and education control groups.

Reporting of ethical standards: differences between complementary and orthodox medicine journals?

OBJECTIVES: This study aimed at assessing whether there are differences in the reporting of ethical aspects of complementary and alternative medicine (CAM) and mainstream medical research. DESIGN: Review of published literature. SETTING: Research department of medical school. MAIN OUTCOME MEASURES: Reports of ethical aspects including adherence to clinical guidelines, ethical approval from ethics committees, consent of the patient, declaration of conflict of interest, and declaration of funding for a study. RESULTS: We included 21 articles from CAM journals, as well as 16 from equal impact factor mainstream (EIF) journals and 27 from high impact factor (HIF) journals. A statistically significant difference was found in the reporting of ethical approval: 62% of all CAM articles, 75% of the EIF and 93% of the HIF journal articles reported approval from ethics committees [chi2 = (2, n = 64) 6.631, p<0.05]. Regarding the reporting of obtaining patients' consent there were no statistically significant differences: 48% of all CAM articles, 38% of the EIF mainstream and 67% of the HIF mainstream journal articles explicitly stated that patients signed a consent form [chi2 = (2, n = 64) 3.813, p>.05]. High impact factor journals were more likely to report on ethical standards than other journals on conflicts of interests and sponsorship. However, they were less likely to report a reference to ethical guidelines. Articles from CAM journals had more strict reporting requirements than mainstream medicine journals with comparable impact factors. CONCLUSIONS: Differences exist between complementary and orthodox medical journals in the reporting of ethical aspects of trial design.

Modernized education of traditional medicine in Korea: is it contributing to the same type of professionalization seen in Western medicine?

In Korea, the teaching of traditional medicine (TM) has been institutionalized for more than five decades, and accordingly the formulated educational system has a structure similar to that of Western medicine (WM). The authors therefore assumed that TM and WM students would share similar attitudes and values regarding professionalism. To test this hypothesis, we administered a questionnaire to TM students nationwide, and compared the results with those of WM students. We found that, despite the large differences in philosophy, concepts, and clinical content between the medical disciplines, the professional socializations of TM and WM students were progressing in a similar way.