International Trend of Non-Contact Healthcare and Related Changes Due to COVID-19 Pandemic.

In response to the global spread of coronavirus disease-2019 (COVID-19), many countries have expanded access to non-contact healthcare. This study aimed to investigate the current state of non-contact healthcare in developed countries before and after the outbreak of the COVID-19 pandemic, and examine the potential clinical and political implications applicable to Korea. Before the COVID-19 outbreak, non-contact healthcare was provided to a limited extent. However, given the surge in COVID-19 cases, countries have lifted the restrictions on non-contact healthcare by expanding eligibility to patients and providers and the range of services. Countries that were slow to implement non-contact healthcare before the pandemic experienced a paradigm shift. Non-contact healthcare has advantages in maintaining essential health services while protecting patients and providers from viral infections. In Korea, non-contact healthcare was regarded as a business sector, so it has not been formally discussed from a public health standpoint. Given this global urgency, discussions should begin surrounding how to best utilize non-contact healthcare, considering the values, safety, and efficacy from the perspective of continuity of patient care. Non-contact healthcare should shift to utilizing a patient-centered approach. The step-by-step strategic planning of non-contact healthcare is imperative for ensuring value, quality, equity, and safety of services.

Preliminary Results of Teleconsultations Temporarily Allowed during the COVID-19 Pandemic.

PURPOSE: During the COVID-19 pandemic, Korea has temporarily expanded coverage of teleconsultation to ensure access to essential health services. As a preliminary study, we investigated service utilization patterns and the characteristics of doctors and patients involved in these temporary teleconsultation services. MATERIALS AND METHODS: Using national health insurance claims data from February 23, 2020 to June 30, 2020 from the Health Insurance Review and Assessment Service, 228269875 cases were identified. Among them, 567390 cases that received teleconsultation services were included in our study. We performed descriptive analyses according to the types of healthcare institutions. RESULTS: In total, 6193 healthcare institutions provided teleconsultation. Of these, 5466 (88.3%) were clinics. Physicians providing teleconsultations were most likely to be doctors of internal medicine (34.0%) or pediatricians (7.0%) and based in the Seoul Metropolitan area (30.4%). In terms of patients undergoing teleconsultation, the most common major disease categories treated were circulatory system diseases (I00-I99). In a detailed analysis, hypertensive diseases (I10-I15) were the most common diagnoses, with a total of 88726 cases (15.6%), followed by diabetes mellitus at 60298 cases (10.6%). The proportion of Medical Aid recipients receiving teleconsultations was higher (9.5%) than other socioeconomic groups. Among all participants, 356622 cases (84.6%) were from a return visit, and 108838 cases (19.2%) received teleconsultation services without being prescribed drugs. CONCLUSION: Temporarily allowed teleconsultation services were provided mostly to the following patients: 1) those scheduled for revisitation, 2) those with chronic diseases, and 3) those living in pandemic hotspots.

Effects of a price cut reform on the cost and utilization of antidiabetic drugs in Korea: a national health insurance database study.

BACKGROUND: Despite the potential widespread application and a significant need, the policy effectiveness of prescribed medications price controls has not been studied extensively. We aimed to explore the effects of a price cut introduced in April 1st of 2012 on the cost and utilization of antidiabetics in South Korea. METHODS: We identified approximately four million outpatients who filed at least one diabetes-related claim during the index period (January 2010 to December 2012) using the National Health Insurance claims data. We performed interrupted time series analyses for cost and utilization of "overall," "reduced price," and "constant price" antidiabetics between January 2009 and June 2013, and measured the growth rate for incidents of medical and surgical procedures for diabetes-induced complications. RESULTS: The segmented regression suggests that spending on overall and reduced price antidiabetics would drop by 6 and 23%, respectively; spending on constant price antidiabetics would rise by 16% in a year after the new pricing compared to if the policy were not in existence. There were a few immediate changes in utilization, and its trend indicated a significant decrease in reduced price antidiabetics and an increase in constant price antidiabetics. Incidents of medical and surgical procedures relating to diabetic complications were unaffected. CONCLUSIONS: The Korean price cut program contained costs by immediately reducing the cost of pharmaceuticals without any major signals associated with compromised clinical conditions in diabetic patients.

Adherence to Inhaled Medications and its Effect on Healthcare Utilization and Costs Among High-Grade Chronic Obstructive Pulmonary Disease Patients.

BACKGROUND: Adherence to inhaled medication regimens affects chronic obstructive pulmonary disease (COPD) prognosis and quality of life, and reduces the use of healthcare services, resulting in cost savings. OBJECTIVES: To examine the effects of adherence to inhaled medication regimens on healthcare utilization and costs in high-grade COPD patients. METHODS: We performed an observational retrospective cohort study using a longitudinal data set from the Korean Health Insurance Review and Assessment Service (2008-2013) containing healthcare services' information for 50 million beneficiaries. The study population was high-grade COPD patients. "Adherent" was defined as a patient attaining a medication possession ratio (MPR) ≥ 80%. We estimated the effects of adherence on the use of intensive care units (ICUs) and emergency rooms (ERs) using a multivariate logistic regression, and estimated the effects on costs (all-cause and COPD-related) using a generalized linear model, with adjustment for patient sociodemographic characteristics, health status, and comorbidities. RESULTS: Of 9086 high-grade COPD patients, adherence declined from 34.7 to 22.3% over 4 years. Adherence was inversely associated with use of ICUs and costs, and this association got stronger as the adherence period lengthened. Over the 4-year period, the adherent group had a lower likelihood of using ICUs [odds ratio (OR) = 0.74, 95% confidence interval (CI) 0.60-0.91] than the non-adherent group. Similarly, the adherent group had a 10.4% lower all-cause cost (p < 0.001) and an 11.7% lower COPD-related cost (p < 0.0001) versus the non-adherent group. CONCLUSIONS: Adherence reduces healthcare utilization and costs, so adherence is not only clinically effective but also economically efficient. However, less than one-quarter of this population remained adherent over the 4-year period, suggesting that strategies are needed to improve adherence.

Identification of subtypes in subjects with mild-to-moderate airflow limitation and its clinical and socioeconomic implications.

PURPOSE: The purpose of this study was to identify subtypes in patients with mild-to-moderate airflow limitation and to appreciate their clinical and socioeconomic implications. METHODS: Subjects who were aged ≥20 years and had forced expiratory volume in 1 second (FEV1) ≥60% predicted and FEV1/forced vital capacity <0.7 were selected from the fourth Korea National Health and Nutrition Examination Survey (KNHANES) in 2007-2012. The data were merged to the National Health Insurance reimbursement database during the same period. k-Means clustering was performed to explore subtypes. For clustering analysis, six key input variables - age, body mass index (BMI), FEV1% predicted, the presence or absence of self-reported wheezing, smoking status, and pack-years of smoking - were selected. RESULTS: Among a total of 2,140 subjects, five groups were identified through k-means clustering, namely putative "near-normal (n=232)," "asthmatic (n=392)," "chronic obstructive pulmonary disease (COPD) (n=37)," "asthmatic-overlap (n=893)," and "COPD-overlap (n=586)" subtypes. Near-normal group showed the oldest mean age (72±7 years) and highest FEV1 (102%±8% predicted), and asthmatic group was the youngest (46±9 years). COPD and COPD-overlap groups were male predominant and all current or ex-smokers. While asthmatic group had the lowest prescription rate despite the highest proportion of self-reported wheezing, COPD, asthmatic-overlap, and COPD-overlap groups showed high prescription rate of respiratory medicine. Although COPD group formed only 1.7% of total subjects, they showed the highest mean medical cost and health care utilization, comprising 5.3% of the total medical cost. When calculating a ratio of total medical expense to household income, the mean ratio was highest in the COPD group. CONCLUSION: Clinical and epidemiological heterogeneities of subjects with mild-to-moderate airflow limitation and a different level of health care utilization by each subtype are shown. Identification of a subtype with high health care demand could be a priority for effective utilization of limited resources.

Towards Actualizing the Value Potential of Korea Health Insurance Review and Assessment (HIRA) Data as a Resource for Health Research: Strengths, Limitations, Applications, and Strategies for Optimal Use of HIRA Data.

Health Insurance and Review Assessment (HIRA) in South Korea, also called National Health Insurance (NHI) data, is a repository of claims data collected in the process of reimbursing healthcare providers. Under the universal coverage system, having fee-for-services covering all citizens in South Korea, HIRA contains comprehensive and rich information pertaining to healthcare services such as treatments, pharmaceuticals, procedures, and diagnoses for almost 50 million beneficiaries. This corpus of HIRA data, which constitutes a large repository of data in the healthcare sector, has enormous potential to create value in several ways: enhancing the efficiency of the healthcare delivery system without compromising quality of care; adding supporting evidence for a given intervention; and providing the information needed to prevent (or monitor) adverse events. In order to actualize this potential, HIRA data need to actively be utilized for research. Thus understanding this data would greatly enhance this potential. We introduce HIRA data as an important source for health research and provide guidelines for researchers who are currently utilizing HIRA, or interested in doing so, to answer their research questions. We present the characteristics and structure of HIRA data. We discuss strengths and limitations that should be considered in conducting research with HIRA data and suggest strategies for optimal utilization of HIRA data by reviewing published research using HIRA data.

Natural course of early COPD.

BACKGROUND AND OBJECTIVE: Few studies have examined the natural course of early COPD. The aim of this study was to observe the natural course of early COPD patients. We also aimed to analyze medical utilization and costs for early COPD during a 6-year period. METHODS: Patients with early COPD were selected from Korean National Health and Nutrition Examination Survey (KNHANES) data. We linked the KNHANES data of patients with early COPD to National Health Insurance data. RESULTS: A total of 2,397 patients were enrolled between 2007 and 2012. The mean forced expiratory volume in 1 second (FEV1) was 78.6%, and the EuroQol five dimensions questionnaire (EQ-5D) index value was 0.9. In total, 110 patients utilized health care for COPD in 2007, and this number increased to 179 in 2012. The total mean number of days used per person increased from 4.9 in 2007 to 7.8 in 2012. The total medical cost per person also increased from 248.8 US dollar (USD) in 2007 to 780.6 USD in 2013. A multiple linear regression revealed that age, lower body mass index, lower FEV1 (%), and lower EQ-5D score were significantly associated with medical costs. CONCLUSION: Even in early COPD patients, some of them eventually progressed and utilized health care for COPD.

Trend of cost and utilization of COPD medication in Korea.

BACKGROUND: There are only a few longitudinal studies regarding medical utilization and costs for patients with COPD. The purpose of this study was to analyze the trend of medical utilization and costs on a long-term basis. METHODS: Using the Korean Health Insurance Review and Assessment Service (HIRA) data from 2008 to 2013, COPD patients were identified. The trend of medical utilization and costs was also analyzed. RESULTS: The number of COPD patients increased by 13.9% from 2008 to 2013. During the same period, the cost of COPD medication increased by 78.2%. Methylxanthine and systemic beta agonists were most widely prescribed between 2008 and 2013. However, inhaled medications such as long-acting beta-2 agonist (LABA), long-acting muscarinic agonist, and inhaled corticosteroid plus LABA were dispensed to a relatively low proportion of patients with COPD. The number of patients who were prescribed inhaled medications increased gradually from 2008 to 2013, while the number of patients prescribed systemic beta agonist and methylxanthine has decreased since 2010. CONCLUSION: This study shows that there is a large gap between the COPD guidelines and clinical practice in Korea. Training programs for primary care physicians on diagnosis and guideline-based treatment are needed to improve the management of COPD.

Impacts of coexisting bronchial asthma on severe exacerbations in mild-to-moderate COPD: results from a national database.

BACKGROUND: Acute exacerbations are major drivers of COPD deterioration. However, limited data are available for the prevalence of severe exacerbations and impact of asthma on severe exacerbations, especially in patients with mild-to-moderate COPD. METHODS: Patients with mild-to-moderate COPD (≥40 years) were extracted from Korean National Health and Nutrition Examination Survey data (2007-2012) and were linked to the national health insurance reimbursement database to obtain medical service utilization records. RESULTS: Of the 2,397 patients with mild-to-moderate COPD, 111 (4.6%) had severe exacerbations over the 6 years (0.012/person-year). Severe exacerbations were more frequent in the COPD patients with concomitant self-reported physician-diagnosed asthma compared with only COPD patients (P<0.001). A multiple logistic regression presented that asthma was an independent risk factor of severe exacerbations in patients with mild-to-moderate COPD regardless of adjustment for all possible confounding factors (adjusted odds ratio, 1.67; 95% confidence interval, 1.002-2.77, P=0.049). In addition, age, female, poor lung function, use of inhalers, and low EuroQoL five dimensions questionnaire index values were independently associated with severe exacerbation in patients with mild-to-moderate COPD. CONCLUSION: In this population-based study, the prevalence of severe exacerbations in patients with mild-to-moderate COPD was relatively low, compared with previous clinical interventional studies. Coexisting asthma significantly impacted the frequency of severe exacerbations in patients with mild-to-moderate COPD, suggesting application of an exacerbation preventive strategy in these patients.

Secular Trends of Gestational Diabetes Mellitus and Changes in Its Risk Factors.

OBJECTIVE: The aim of this study was to evaluate the secular trends of incidence of gestational diabetes mellitus (GDM) and insulin treatment for GDM in a Korean population and to determine the factors that contribute to the trends in the incidence of GDM. STUDY DESIGN: We used data collected by the Health Insurance Review & Assessment Service of Korea and analyzed data from women who had given birth from 2006 to 2010. We evaluated the trends in the incidence of GDM and GDM requiring insulin treatment and the changes in risk factors. RESULTS: There were 1,824,913 births during the study period, which included 129,666 cases of GDM, an incidence of 7.11% over this period. The incidence of GDM increased from 3.86% in 2007 to 11.83% in 2010, with a continuous increase after adjustment for age. However, the number of GDM cases that required insulin treatment decreased significantly from 13.87% in 2007 to 5.94% in 2010. The proportion of patients who were at an older age and multiparity, 2 GDM risk factors, increased during the study period. CONCLUSIONS: In Korea, the incidence of GDM, especially mild GDM, increased dramatically during the period from 2006 to 2010. Further efforts are needed to monitor this trend and to identify associated factors.

A guide for the utilization of Health Insurance Review and Assessment Service National Patient Samples.

The claims data of the Health Insurance Review and Assessment Service (HIRA) is an important source of information for healthcare service research. The claims data of HIRA is collected when healthcare service providers submit a claim to HIRA to be reimbursed for a service that they provided to patients. To improve the accessibility of healthcare service researchers to claims data of HIRA, HIRA has developed the Patient Samples which are extracted using a stratified randomized sampling method. The Patient Samples of HIRA consist of five tables: a table for general information (Table 20) containing socio-demographic information such as gender, age and medical aid, indicators for inpatient and outpatient services; a table for specific information on healthcare services provided (Table 30); a table for diagnostic information (Table 40); a table for outpatient prescriptions (Table 53) and a table for information on healthcare service providers (Table of providers). Researchers who are interested in using the Patient Sample data for research can apply via HIRA's website (https://www.hira.or.kr).

Primary Position Upbeat Nystagmus during an Acute Attack of Multiple Sclerosis.

BACKGROUND AND PURPOSE: Ocular manifestation is one of the frequent signs of an acute attack in multiple sclerosis (MS), although primary position upbeat nystagmus (PPUN) is rare. The purpose of this study is to determine the incidence of PPUN in MS and to determine the lesions that are responsible for this sign. METHODS: The medical records of 120 MS patients with acute brain lesions were reviewed over a consecutive period of 9 years; of these, 6 patients were found to have PPUN. Other ocular motor abnormalities were analyzed in combination with upbeat nystagmus, video-oculographic findings, and lesions detected on brain MRI. RESULTS: Lesions in the pontine tegmentum involving the medial longitudinal fasciculus (MLF) and ventral tegmental tract (VTT) were the most common, being observed in three of the six patients with PPUN. One patient exhibited caudal medullary lesions bilaterally affecting the paramedian portion of the posterior tegmentum, and two patients exhibited multiple lesions involving the pons with the cerebral peduncle or medulla. In five patients, other ocular motor dysfunctions, such as gaze-evoked nystagmus (n=3) and internuclear ophthalmoplegia (n=1), were found in combination with upbeat nystagmus. CONCLUSIONS: PPUN is an infrequent, ocular manifestation noted during an acute attack of MS, and was observed in 5% of the present cases. Brainstem lesions in these cases primarily involved the pontine tegmentum and the caudal medulla. These findings support the theory that upbeat nystagmus is attributable to damage to the upward vestibulo-ocular reflex pathway related to the vestibular nucleus, VTT, and interconnecting pathways.

A patient with coexisting myasthenia gravis and lambert-eaton myasthenic syndrome.

BACKGROUND: The coexistence of myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS) is very rare and remains controversial. CASE REPORT: A 48-year-old woman initially presented with noticeable right ptosis and intermittent diplopia. She then developed fluctuating proximal limb weakness and difficulty in swallowing. The serum titer of anti-acetylcholine-receptor antibody was elevated and the edrophonium (Tensilon) test was positive. However, repetitive nerve stimulation revealed abnormalities typical of LEMS. The patient exhibited a good response to treatment with anticholinesterase inhibitors and steroids, and long-term evaluation disclosed that she presented with the clinical, electrophysiological, and immunological characteristics of both diseases. CONCLUSIONS: The reported clinical and electrophysiological features suggest that this patient was a very rare case of combined MG and LEMS.

Comparison of statin adherence among beneficiaries in MA-PD plans versus PDPs.

BACKGROUND: Medicare Part D, which provides prescription drug coverage to Medicare beneficiaries, is delivered through either Medicare Advantage prescription drug (MA-PD) plans or stand-alone prescription drug plans (PDPs). MA-PD plans cover both drug therapy and other medical services, whereas PDPs provide prescription drug coverage only. Because of the potential substitutability between prescription drugs and other medical services, MA-PD plans may make greater efforts to improve enrollees' adherence to recommended medications than PDPs. Prescription drug benefits are more generous in MA-PD plans than in PDPs. OBJECTIVE: To assess statin adherence, comparing Medicare beneficiaries in MA-PD plans with those in PDPs. METHODS: We used records from the Chronic Condition Warehouse 2007 Prescription Drug Event (PDE) file, associated Plan Characteristics files, and the Beneficiary Summary File (BSF) for a 5% random sample of Medicare beneficiaries. The study sample comprised Medicare beneficiaries aged 65 years or older in 2006 who filled at least 1 prescription for a statin during 2007, excluding beneficiaries with low-income subsidy or end-stage renal disease and those without both Medicare Part A and Part B enrollment in 2007. Medication adherence was measured by medication possession ratio (MPR), defined as the sum of days supply for all statin prescriptions filled in 2007 minus the days supply that would have carried over into 2008 from the final 2007 prescription filled, divided by the total number of days from the fill date of the first statin prescription to December 31, 2007. A binary indicator of good adherence was defined as MPR exceeding 80%. Propensity-score matching was used to reduce differences in observed characteristics of enrollees in MA-PD plans and PDPs. The propensity score was based on sociodemographic characteristics and health risk measures, including Hierarchical Condition Category (HCC) scores. RESULTS: In the unmatched sample, the mean MPR was 70.57% for MA-PD enrollees versus 70.54% for PDP enrollees (P = 0.780), and the proportion of enrollees with good adherence was 46.7% for MA-PD plans versus 46.9% for PDPs (P = 0.262). In the matched sample, statin adherence was slightly better among MA-PD enrollees than PDP enrollees. Mean MPRs were 70.80% and 69.44%, and the percentages of enrollees with good adherence were 47.0% and 45.3% in MA-PD plans and PDPs, respectively (both P less than 0.001). CONCLUSIONS: During an early year of the Part D program, MA-PD enrollees had slightly better adherence to statin therapy than PDP enrollees. While the difference was statistically significant, it was very small and unlikely to lead to clinically meaningful consequences. Less than one-half of MA-PD and PDP enrollees had good adherence in statin use, suggesting room for improvement in both types of Part D plans. Continuing evaluations of adherence in diverse therapy classes are needed for Medicare Part D beneficiaries.

A case of vascular hemichorea responding to topiramate.

Although vascular chorea often comes into remission spontaneously, a few patients may remain with persistent movement disorder. Most movements respond well to neuroleptics as well as other antidopaminergic drugs, but some patients show poor responses to those neuroleptics. Topiramate is a widely used of broad-spectrum anticonvulsant possessing a complex mechanism of action. It has been proven to enhance gamma-aminobutyrate acid activity and to be effective in the control of other movement disorders. We describe a 63-year-old woman with intractable vascular hemichorea which was controlled with anti-convulsant, topiramate.

An integrated approach to oversight assessment for emerging technologies.

Analysis of oversight systems is often conducted from a single disciplinary perspective and by using a limited set of criteria for evaluation. In this article, we develop an approach that blends risk analysis, social science, public administration, legal, public policy, and ethical perspectives to develop a broad set of criteria for assessing oversight systems. Multiple methods, including historical analysis, expert elicitation, and behavioral consensus, were employed to develop multidisciplinary criteria for evaluating oversight of emerging technologies. Sixty-six initial criteria were identified from extensive literature reviews and input from our Working Group. Criteria were placed in four categories reflecting the development, attributes, evolution, and outcomes of oversight systems. Expert elicitation, consensus methods, and multidisciplinary review of the literature were used to refine a condensed, operative set of criteria. Twenty-eight criteria resulted spanning four categories: seven development criteria, 15 attribute criteria, five outcome criteria, and one evolution criterion. These criteria illuminate how oversight systems develop, operate, change, and affect society. We term our approach "integrated oversight assessment" and propose its use as a tool for analyzing relationships among features, outcomes, and tradeoffs of oversight systems. Comparisons among historical case studies of oversight using a consistent set of criteria should result in defensible and evidence-supported lessons to guide the development of oversight systems for emerging technologies, such as nanotechnology.